Disposal of a nonviable fetus in a humane fashion shall consist of incineration, burial, or cremation. The licensed physician performing the abortion or the licensed hospital in which an abortion is performed may contract for out-of-state incineration, burial, or cremation of nonviable fetuses. Incinerators within the state of North Dakota used for the disposal of nonviable fetuses must meet the requirement of chapter 33-15-14.

History: Effective March 1, 1988.

General Authority: NDCC 14-02.1-09, 23-01-03

Law Implemented: NDCC 14-02.1-09

INDUCED ABORTION DISCLOSURE AND CONSENT FORM

PHYSICIAN'S DISCLOSURE AND STATEMENT CONCERNING ABORTION

1. Concerning the state of development of the fetus: ____

2. Concerning the method of abortion to be utilized and the effects of this method upon the fetus: ____

3. Concerning possible physical and psychological complications of abortion: ____

4. Concerning available alternatives to abortion (e.g., childbirth, adoption): ____

I hereby certify that I have fully disclosed the above information to the undersigned individual regarding the abortion to which she has voluntarily consented.

Physician's Signature: ____ Date: _

PATIENT CERTIFICATION AND CONSENT

I hereby certify that the above disclosures have been fully stated to me and that I consent to the performance of this abortion of my own volition and without duress.

Patient's Signature: ____ Date: _

ADDITIONAL CERTIFICATION AND CONSENT FOR ABORTION IN WHICH THE FETUS HAS REACHED A GESTATIONAL AGE OF 12 WEEKS OR MORE

I hereby certify that I am the legal husband of the above mentioned patient and that I voluntarily consent to this abortion of my own volition and without duress.

Husband's Signature: ____ Date: _

OR

I hereby certify that I am the (parent, legal guardian) of the above mentioned patient and that I voluntarily consent to this abortion of my own volition without duress.

Signature of Parent or Legal Guardian: ____ Date: _

NORTH DAKOTA STATE DEPARTMENT OF HEALTH

OFFICE OF STATISTICAL SERVICES REPORT OF INDUCED ABORTION

APPENDIX B

MARITAL OR FACILITY INFORMATION
NAME OF FACILITY	CITY
COUNTY	STATE
PATIENT INFORMATION
CITY-RESIDENCE	INSIDE CITY LIMITS (YES OR NO)
COUNTY-RESIDENCE	STATE-RESIDENCE
DEMOGRAPHIC INFORMATION—PATIENT
DATE OF BIRTH	MARITAL STATUS
RACE	EDUCATION
PREVIOUS LIVE BORN CHILDREN—HOW LIVING	PREVIOUS LIVE BORN CHILDREN—HOW DEAD
PREVIOUS SPONTANEOUS FETAL DEATHS—20 WEEKS OR MORE GESTATION	PREVIOUS SPONTANEOUS ABORTIONS—LESS THAN 20 WEEKS
PREVIOUS INDUCED ABORTIONS
MEDICAL INFORMATION
DATE OF ABORTION	FIRST DAY OF LAST NORMAL MENSTRUAL PERIOD (LMP)
PHYSICIAN'S ESTIMATE OF LENGTH OF GESTATION—WEEKS PHYSICIAN'S SIGNATURE DATE OF SIGNATURE	TYPE OF ABORTION PROCEDURE—PRIMARY PROCEDURE SUCTION CURRETAGE ☐ HYSTEROTOMY ☐ SALINE INFUSION ☐ HYSTERECTOMY ☐ FROSTAGLANOINS ☐ OTHER-SPECIFY ☐ SHARP CURRETAGE ☐
WERE PATHOLOGY STUDIES FILED? YES ☐ NO ☐ HAVE CONSENT FORMS BEEN COMPLETED AND FILED? YES ☐ NO ☐ WAS THERE AN INDICATION OF FETAL VIABILITY PER VITAL SIGNS? YES ☐ NO ☐ DESCRIBE MEDICAL PROCEDURES EMPLOYED TO PRESERVE THE LIFE AND HEALTH OF THE FETUS. In compliance with the provisions of Chapter 14-02.1 of the North Dakota Century Code, I hereby certify that the above information is accurate to the best of my knowledge. Certifier's Signature and Title ___ Date: _