2023 Oklahoma Statutes › Title 63. Public Health and Safety › §63-1-738k. Posting of Individual Abortion Form - Notice - Sample 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 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
(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:______________
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 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: ________
Parents want mother to have an abortion: _________
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? _____
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 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? ______________
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: ___________________
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: ___________
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 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)
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.
Added by Laws 2010, c. 276, § 3, eff. Nov. 1, 2010. Amended by Laws 2013, c. 303, § 1, eff. Nov. 1, 2013.
NOTE: The conditional repeal of this section by Laws 2021, c. 308, § 2, was itself repealed by Laws 2022, c. 133, § 2, emerg. eff. April 29, 2022.