1. 1. FACILITY NAME AND ADDRESS WHERE COMPLICATION WAS DIAGNOSED
2. 2. PATIENT IDENTIFICATION NUMBER
3. 3. REPORTING PHYSICIAN'S IDFPR LICENSE NUMBER

4. 4. 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)

5. 5. RACE/ETHNICITY

   1. 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)

   2. b. Hispanic Origin

      No, not Spanish/Hispanic/Latina

      Mexican, Mexican American, Chicana

      Puerto Rican

      Cuban

      Other Spanish/Hispanic/Latina

6. 6. AGE LAST BIRTHDAY
7. 7. MARRIED/CIVIL UNION?
8. 8. DATE OF PREGNANCY TERMINATION (Mo/Day/Year)

9. 9. COMPLICATIONS OF PREGNANCY TERMINATION (check all that apply)

   Hemorrhage

   Uterine Perforation

   Anesthesia

   Retained Products

   Cervical Laceration

   Infection

   Death

   Other (Specify)

10. 10. HOSPITAL ADMISSION REQUIRED ON DATE OF EXAMINATION?

    1. 11. FACILITY NAME OR LOCATION (IF KNOWN) WHERE THE ABORTION WAS PERFORMED

    Y N

REPORT OF SUBSEQUENT COMPLICATIONS AFTER

AN INDUCED TERMINATION OF PREGNANCY

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)