Okla. Stat. tit. 63, § 63-1-738k

form.

A. Subsections B and C of this section shall become operative

on the later of:

1. April 1, 2012; or

2. Thirty (30) calendar days following the date on which the

State Department of Health posts on its website the Individual

Abortion Form and instructions concerning its electronic submission

referenced in this section.

B. The Department shall post the Individual Abortion Form and

instructions concerning its electronic submission on its stable

Internet website. Nothing in the Individual Abortion Form shall

Oklahoma Statutes - Title 63. Public Health and Safety Page 344

contain the name, address, hometown, county of residence, or any

other information specifically identifying any patient. The

Department's Individual Abortion Form shall be substantially similar

to, but need not be in the specific format, provided in subsection F

of this section.

C. Any physician performing abortions shall fully complete and

submit, electronically, an Individual Abortion Form to the State

Department of Health by the last business day of the calendar month

following the month in which the physician performs an abortion, for

each abortion the physician performs.

D. In cases in which a physician or the agent of a physician:

1. Mails the printed materials described in Section 1-738.3 of

this title to a female specifically to comply with division (1) of

subparagraph d of paragraph 2 of subsection B of Section 1-738.2 of

this title;

2. Gives or mails the printed materials described in Section 1-

738.10 of this title to a female specifically to comply with

subsection A of Section 1-738.8 of this title; or

3. Provides notice to a parent in compliance with Section 1-

740.2 of this title,

but does not subsequently perform an abortion on the female or

minor, the physician shall electronically submit a completed

Individual Abortion Form to the State Department of Health, and

shall mark as "not applicable" those items of information that may

accurately be provided only when an abortion is performed. The

physician shall not submit such a form if the physician knows that

an abortion was subsequently performed on the female or minor by

another physician. Individual Abortion Forms required by this

subsection shall be submitted by the last business day of the second

calendar month following the calendar month in which the physician

mails the printed materials or provides notice to a parent.

E. The Individual Abortion Form shall contain a notice

containing an assurance that, in accordance with subsection F of

Section 1-738m of this title, public reports based on the form

submitted will not contain the name, address, hometown, county of

residence, or any other identifying information of any individual

female, that the State Department of Health will take care to ensure

that none of the information included in its public reports could

reasonably lead to the identification of any individual female about

whom information is reported in accordance with the Statistical

Abortion Reporting Act or of any physician providing information in

accordance with the Statistical Abortion Reporting Act, and that

such information is not subject to the Oklahoma Open Records Act.

F. Individual Abortion Form. The Department's Individual

Abortion Form shall be substantially similar to, but need not be in

the specific format of, the following form:

Individual Abortion Form

Oklahoma Statutes - Title 63. Public Health and Safety Page 345

(TO BE COMPLETED FOR EACH ABORTION PERFORMED)

1. Date of abortion: _________________

2. County in which the abortion was performed: ________________

3. Age of mother: _________________

4. Marital status of mother: ________________

(specify married, divorced, separated, widowed, or never

married)

5. Race of mother: ________________

6. Years of education of mother: ________________

(specify highest year completed)

7. State or foreign country of residence of

mother:______________
unty in which the abortion was performed: ________________

3. Age of mother: _________________

4. Marital status of mother: ________________

(specify married, divorced, separated, widowed, or never

married)

5. Race of mother: ________________

6. Years of education of mother: ________________

(specify highest year completed)

7. State or foreign country of residence of

mother:______________

8. Total number of previous pregnancies of the

mother:___________

Live Births: _________________

Miscarriages: _________________

Induced Abortions: __________________

9. Approximate gestational age in weeks, as measured from the

last menstrual period of the mother, of the unborn child subject to

abortion: _______________________________

10. Method of abortion used:

Suction Aspiration: ___________

Dilation and Curettage: ___________

RU 486: ___________

Methotrexate: ___________

Other drug/chemical/medicine (specify): _________________

Dilation and Evacuation: ___________

Saline: ___________

Urea: ___________

Prostaglandins: ___________

Partial Birth Abortion: __________

Hysterotomy: ___________

Other (specify): ___________

11. Was there an infant born alive as a result of the abortion?

__________

If yes:

Were life-sustaining measures undertaken? ___________

How long did the infant survive? ___________

12. Was anesthesia administered to mother? ____________

If yes, what type? ____________________________

13. Was anesthesia administered to the fetus? ___________

If yes:

What type? _______________________

How was it administered? _______________________

14. Method of fetal tissue disposal: _______________________

15. Unless a medical emergency, as defined in Section 1-738.1A,

or as applicable, Section 1-745.2 of Title 63 of the Oklahoma

Oklahoma Statutes - Title 63. Public Health and Safety Page 346

Statutes, exists, the abortion provider or agent shall ask the

pregnant female to provide, orally or in writing, the reason(s) she

is seeking the abortion. If such a medical emergency exists, the

abortion provider or agent shall specify on the form the condition

which necessitated the immediate abortion: ___________________

REASON GIVEN FOR ABORTION (check all applicable):

Having a baby:

Would dramatically change the life of the mother: _________

Would interfere with the education of the mother: _________

Would interfere with the job/employment/career of the

mother: ______

Mother has other children or dependents: ________

Mother cannot afford the child: ______

Mother is unmarried: ________

Mother is a student or planning to be a student: ________

Mother cannot afford child care: _______

Mother cannot afford the basic needs of life: ________

Mother is unemployed: _________

Mother cannot leave job to care for a baby: _________

Mother would have to find a new place to live: _________

Mother does not have enough support from a husband or partner:

_____

Husband or partner is unemployed: _______

Mother is currently or temporarily on welfare or public

assistance: _________

Mother does not want to be a single mother: _______

Mother is having relationship problems: ________

Mother is not certain of relationship with the father of the

child: ________

Partner and mother are unable to or do not want to get married:

_______

Mother is not currently in a relationship: _______

The relationship or marriage of the mother may soon break up:

_______

Husband or partner is abusive to the mother or her children:

_______

Mother has completed her childbearing: ________

Mother is not ready for a, or another, child: _______

Mother does not want people to know that she had sex or became

pregnant: ________

Mother does not feel mature enough to raise a, or another,

child: _______

Husband or partner wants mother to have an abortion: ______

There may be possible problem affecting the health of the

fetus: ________

Physical health of the mother is at risk: ________
ther is not ready for a, or another, child: _______

Mother does not want people to know that she had sex or became

pregnant: ________

Mother does not feel mature enough to raise a, or another,

child: _______

Husband or partner wants mother to have an abortion: ______

There may be possible problem affecting the health of the

fetus: ________

Physical health of the mother is at risk: ________

Parents want mother to have an abortion: _________

Oklahoma Statutes - Title 63. Public Health and Safety Page 347

Emotional health of the mother is at risk: ________

Mother suffered from a medical emergency as defined in Section

1-738.1A of Title 63 of the Oklahoma Statutes: ______

Mother suffered from a medical emergency as defined in Section

1-745.2 of Title 63 of the Oklahoma Statutes: _____

Mother wanted a child of a different sex: ______

Abortion is necessary to avert the death of the mother: ______

Pregnancy was a result of forcible rape: ______

Pregnancy was a result of incest: ______

Other (specify): ______

Patient was asked why she is seeking an abortion, but she

declined to give a reason: _______

16. Method of payment (check one):

Private insurance: _______

Public health plan: _______

Medicaid: _______

Private pay: _______

Other (specify): _____________________________

17. Type of private medical health insurance coverage, if any

(check one):

Fee-for-service insurance company: ______

Managed care company: ______

Other (specify): _____________________________

18. Sum of fee(s) collected: ___________

19. Time of fee collection (check one):

Full fee for abortion collected prior to or at the time the

patient was provided the information required under subsection B of

Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________

Partial fee for abortion collected prior to or at the time the

patient was provided the information required under subsection B of

Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________

Full fee for abortion collected at time the abortion was

performed: ________

Other (specify): ________

20. Specialty area of medicine of the physician: _____________

At which hospital(s) did the physician have hospital privileges

at the time of the abortion?

______________________________________________________________

21. Was ultrasound equipment used before, during, or after the

performance of this abortion?

Before? _____ Vaginal, abdominal, or both? _____

How long prior to the abortion was the ultrasound performed?

______

Was the mother under the effect of anesthesia at the time of the

ultrasound? ______

During? _____ Vaginal, abdominal, or both? _____

After? _____ Vaginal, abdominal, or both? _____

Oklahoma Statutes - Title 63. Public Health and Safety Page 348

If an ultrasound was performed, what was the gestational age of

the fetus at the time of the abortion, as determined by the

ultrasound? _____________

Attach to this form a copy or screenshot of the ultrasound,

intact with the date on which the ultrasound was performed, and with

the name of the mother redacted; provided, however, such ultrasound

shall not be subject to an open records request and shall be subject

to HIPAA regulations governing confidentiality and release of

private medical records.

21A. If an ultrasound was not performed prior to the abortion,

was the reason for not performing an ultrasound a medical emergency

necessitating an immediate abortion:

To avert death: _______

To avert substantial and irreversible impairment of a major

bodily function arising from continued pregnancy: _______

Other reason: ____________

22. If ultrasound equipment was used, was the ultrasound

performed by:

The physician performing the abortion: _____

A physician other than the physician performing the abortion:

_____

Other (specify): ___________________________

23. Was the information required by paragraph 1 of subsection B
nt of a major

bodily function arising from continued pregnancy: _______

Other reason: ____________

22. If ultrasound equipment was used, was the ultrasound

performed by:

The physician performing the abortion: _____

A physician other than the physician performing the abortion:

_____

Other (specify): ___________________________

23. Was the information required by paragraph 1 of subsection B

of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to

the mother? ___________

a. If yes, was it provided:

In person: ___________

By telephone: ___________

b. Was it provided by:

A referring physician: __________

The physician performing the abortion: _________

An agent of a referring physician: ___________

An agent of the physician performing the abortion: ________

24. Was the information required by paragraph 2 of subsection B

of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to

the mother? _________

a. If yes, was it provided:

In person: _______

By telephone: _______

b. Was it provided by:

A referring physician: _______

An agent of a referring physician: _______

The physician performing the abortion: ________

An agent of the physician performing the abortion: _______

25. Did the mother avail herself of the opportunity to have the

printed materials described in Section 1-738.3 of Title 63 of the

Oklahoma Statutes mailed to her? ______________

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26. Were the informed consent requirements of subsection B of

Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with

because of a medical emergency necessitating an immediate abortion:

To avert death: ______

To avert substantial and irreversible impairment of a major

bodily function arising from continued pregnancy: _____

27. Was a determination of probable postfertilization age made

as required by Section 1-745.5 of Title 63 of the Oklahoma Statutes?

________

a. If no, was the determination of probable

postfertilization age dispensed with:

To avert death: ________

To avert substantial and irreversible impairment of a

major bodily function arising from continued

pregnancy: _____

b. If yes, what was the probable postfertilization age?

____

What was the method and basis of the determination?

_____

What was the basis for the determination to perform

the abortion:

To avert death: _____

To avert substantial and irreversible impairment of a

major bodily function arising from continued

pregnancy: ____

Was the method of abortion used one that, in

reasonable medical judgment, provided the best

opportunity for the unborn child to survive? _____

If yes, was there an infant born alive as a result of

the abortion? _____

If no, what was the basis of the determination? _____

28. Was the abortion performed within the scope of employment

of an Oklahoma state employee or an employee of an agency or

political subdivision of the state? ________

29. Was the abortion performed with the use of any public

institution, public facility, public equipment, or other physical

asset owned, leased, or controlled by this state, its agencies, or

political subdivisions? _________

30. If the answer to question 28 or 29 is yes:

a. Was the abortion necessary to save the life of the

mother? _______

If yes, what was the life-endangering condition?

__________

b. Did the pregnancy result from an act of forcible rape?

_______

If yes, list the law enforcement authority to which

the rape was reported: ___________________

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List the date of the report: ___________

c. Did the pregnancy result from an act of incest

committed against a minor? _________

If yes, list the law enforcement authority to which

the perpetrator was reported: ________________

List the date of the report: ___________

THIS PORTION TO BE COMPLETED IN CASE OF MINOR

31. Minor's age at the time the abortion was performed:
th and Safety Page 350

List the date of the report: ___________

c. Did the pregnancy result from an act of incest

committed against a minor? _________

If yes, list the law enforcement authority to which

the perpetrator was reported: ________________

List the date of the report: ___________

THIS PORTION TO BE COMPLETED IN CASE OF MINOR

31. Minor's age at the time the abortion was performed:

___________

32. Was a parent of the minor provided notice prior to the

abortion as described in Section 1-740.2 of Title 63 of the Oklahoma

Statutes? ________

a. If yes, how was the notice provided?

In person: _______

By mail: _______

b. If yes, to the best of the reporting physician's

knowledge and belief, did the minor go on to obtain

the abortion? ________

33. Was informed written consent of one parent obtained as

described in Section 1-740.2 of Title 63 of the Oklahoma Statutes?

______

If yes, how was it secured?

In person: ___________

Other (specify): _________

34. If no notice was provided nor consent obtained, indicate

which of the following apply:

Minor was emancipated: ___________

Abortion was necessary to prevent the death of the minor: _____

Medical emergency, as defined in Section 1-738.1A of Title 63 of

the Oklahoma Statutes, existed: ___________

Minor received judicial authorization to obtain abortion without

parental notice or consent: ___________

35. If no notice was provided nor consent obtained because a

medical emergency existed, indicate:

Whether parent was subsequently notified (state period of time

elapsed before notice was given): ____________

Whether judicial waiver of notice requirement was obtained:

________

36. If the minor received judicial authorization to obtain an

abortion without parental notice or consent, indicate which of the

following applies:

Judge ruled that minor was mature enough to give informed

consent on her own: ___________

Judge ruled that abortion was in the best interest of the

minor: ___________

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37. If the female was a minor at the time of conception,

indicate the age of the father of the unborn child at the time of

conception: ________

38. If at the time of conception the ages of the mother and

father were such that a violation of Section 1111, 1112, 1114 or

1123 of Title 21 or Section 843.5 of Title 21 of the Oklahoma

Statutes occurred, was the rape or abuse reported to the proper

authorities? ________

39. Were the remains of the fetus after the abortion examined

to ensure that all such remains were evacuated from the mother's

body? _________

If the remains of the fetus were examined after the abortion,

what was the sex of the child, as determined from such examination?

__________

Was the sex of the child determined prior to the abortion?

_________

If so, by whom? _______

If so, by what method? _____

If the sex of the child was determined prior to the abortion,

was the mother given information of the child's sex prior to the

abortion? ________

40. If the abortion was performed without surgery but rather as

the result of the administration of chemicals, was the physician

present in the same room as the woman to whom the chemicals were

administered at the time any such chemicals were first administered?

_______

4l. Prior to the pregnant woman giving informed consent to

having any part of the abortion performed or induced, if the

pregnancy was at least eight (8) weeks after fertilization, was the

pregnant woman told that it may be possible to make the embryonic or

fetal heartbeat of the unborn child audible for the pregnant woman

to hear? _______

Was the pregnant woman asked if she would like to hear the

heartbeat? ______

Was the embryonic or fetal heartbeat of the unborn child made

audible for the pregnant woman to hear, using a Doppler fetal

heart rate monitor? ______

If the response to any of the questions in this paragraph was
e the embryonic or

fetal heartbeat of the unborn child audible for the pregnant woman

to hear? _______

Was the pregnant woman asked if she would like to hear the

heartbeat? ______

Was the embryonic or fetal heartbeat of the unborn child made

audible for the pregnant woman to hear, using a Doppler fetal

heart rate monitor? ______

If the response to any of the questions in this paragraph was

anything other than an unqualified YES, how was the abortion

performed in compliance with Sections 1-745.12 through 1-745.19

of Title 63 of the Oklahoma Statutes? ________

Filed this ____ day of __________, _____, by:

______________________________

(Name of physician)

_____________________________

(Physician's license number)

Oklahoma Statutes - Title 63. Public Health and Safety Page 352

NOTICE: In accordance with subsection F of Section 1-738m of Title

63 of the Oklahoma Statutes, public reports based on this form will

not contain the name, address, hometown, county of residence, or any

other identifying information of any individual female. The State

Department of Health shall take care to ensure that none of the

information included in its public reports could reasonably lead to

the identification of any individual female about whom information

is reported or of any physician providing information in accordance

with the Statistical Abortion Reporting Act. Such information is

not subject to the Oklahoma Open Records Act.

Be advised that any complication(s) shall be detailed in a

"Complications of Induced Abortion Report" and submitted to the

Department as soon as is practicable after the encounter with the

induced-abortion-related illness or injury, but in no case more than

sixty (60) days after such an encounter.