Ill. Admin. Code tit. 77, § 505.APPENDIX B – Induced Termination of Pregnancy Report

1. FACILITY NAME (If not ambulatory surgical treatment centers, hospitals, and other facilities, give address)
2. COUNTY OF PREGNANCY TERMINATION (See County Code table)
3. PATIENT IDENTIFICATION NUMBER
4. REPORTING PHYSICIAN'S IDFPR LICENSE NUMBER
5. PATIENT INFORMATION
1. a. PATIENT'S RESIDENT STATE (See State Code table)
2. b. COUNTY (See County Code table)
3. c. ZIP CODE (Chicago only)
4. 6. RACE/ETHNICITY
5. a. Race
  White
  Black or African American
  American Indian or Alaska Native (Name of the enrolled or principal tribe)
  Asian Indian
  Chinese
  Filipino
  Japanese
  Korean
  Vietnamese
  Other Asian (Specify)
  Native Hawaiian
  Guamanian or Chamorro
  Samoan
  Other Pacific Islander (Specify)
  Other (Specify)
6. b. Hispanic Origin
  No, not Spanish/Hispanic/Latina
  Mexican, Mexican American, Chicana
  Puerto Rican
  Cuban
  Other Spanish/Hispanic/Latina
7. AGE LAST BIRTHDAY
8. MARRIED/CIVIL UNION?
9. DATE OF PREGNANCY TERMINATION (Mo/Day/Year)
10. EDUCATION (Specify only highest grade completed)
Elementary/Secondary (0-12)
College (1-4 or 5+)
11. CLINICAL ESTIMATE OF GESTATION (Number of Weeks)
12. PREVIOUS PREGNANCIES (Complete each section)
1. a. NOW LIVING (Number)
2. b. NOW DEAD (Number)
  OTHER TERMINATIONS
3. a. SPONTANEOUS (Number)
4. b. INDUCED (Number) (Do not include this termination)
LIVE BIRTHS
13. Rh DETERMINATION (Not done/Rh Pos/Rh Neg)
1. 14. IF Rh NEGATIVE, ANTI Rh (Given/Not offered to patient/Refused by patient/Medically not indicated)
15. REASON FOR TERMINATION (Patient's Request/Other)
16. TERMINATION PROCEDURES
1. a. PROCEDURE THAT TERMINATED PREGNANCY (check only one)
  1. b. ADDITIONAL PROCEDURES USED FOR THIS TERMINATION, IF ANY
  Antiprogestins (such as Mifepristone)
  Suction Curettage
  Sharp Curettage
  Dilation and Evacuation (D & E)
  Intra-Uterine Saline Instillation
  Intra-Prostaglandin Instillation
  Hysterotomy
  Hysterectomy
  Other (Specify)
17. COMPLICATIONS OF PREGNANCY TERMINATION? Y N (check all that apply)
Hemorrhage
Uterine Perforation
Anesthesia
Retained Products
Cervical Laceration
Infection
Death
Other (Specify)
18. HOSPITALIZATION REQUIRED AS A RESULT OF COMPLICATION(S)?
Y N
19. This is a corrected version of a previously submitted form. Y

INDUCED TERMINATION OF PREGNANCY REPORT

COMPLETE THIS FORM AND MAIL IT TO:

Illinois Department of Public Health, Division of Vital Records

925 E. Ridgely Ave., Springfield IL 62702-2737

(All information submitted shall be confidential pursuant to the Pregnancy Termination Report Code (77 Ill. Adm. Code 505))

(Source: Added at 37 Ill. Reg. 1744, effective January 23, 2013)