reglab/statecodes huggingface dataset:
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION I - Denial of Information Exchange Form

Current through Register Vol. 48, No. 28, July 12, 2024
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				  image
I, a Notary Public, in and for the said county, in the state
				  aforesaid, do hereby certify that _______________ personally known to me to be
				  the same person whose name is subscribed to the foregoing Denial of Information
				  Exchange, appeared before me in person and acknowledged that he/she signed such
				  authorization as his/her free and voluntary act and that the statements in such
				  authorization are true.
Given under my hand and notarial seal on
,
___________________________________
(insert date)
____________________________________
SIGNATURE OF NOTARY
Illinois Department of Public Health, Division of Vital
				  Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.8 (rev.04/2000)Printed by
				  Authority of the State of Illinois PO# 30M 02/00
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION J - Instructions for Applying for a New Birth Certificate for a Legitimated Child

Current through Register Vol. 48, No. 28, July 12, 2024
REPLY TO: DIVISION OF VITAL
				  RECORDS
INSTRUCTIONS FOR APPLYING
				  FOR A
NEW BIRTH CERTIFICATE FOR
				  A LEGITIMATED CHILD
If the parents of an illegitimate child intermarry after the
				  birth of that child was registered, the law authorizes the State Registrar of
				  Vital Records to replace the birth certificate originally filed with a new one.
				  The new certificate is equivalent to one that would have been filed had the
				  parents of the child been married to each other prior to the registration of
				  the birth. The application for a new birth certificate must be made to the
				  Division of Vital Records, Illinois Department of Public Health, Springfield,
				  Illinois 62702, and shall include the following:
1) A CERTIFIED COPY of the marriage record of
				the natural mother and the natural father. This MUST BE SECURED FROM THE COUNTY
				CLERK of the county in which the marriage was performed.
2) An affidavit by the natural mother, on the
				enclosed form. The affidavit MUST BE PERSONALLY SIGNED IN INK BY THE NATURAL
				MOTHER IN THE PRESENCE OF A NOTARY PUBLIC. All entries on the affidavit, except
				signatures, must be filled in by typewriter or printed in ink.
3) An affidavit by the natural father, on the
				enclosed form. The affidavit MUST BE PERSONALLY SIGNED IN INK BY THE NATURAL
				FATHER IN THE PRESENT OF A NOTARY PUBLIC. All entries on the affidavit, except
				signatures, must be filled in by typewriter or printed in ink.
THERE IS A CHARGE OF $15.00 FOR THE PREPARATION AND FILING OF
				  THE NEW BIRTH CERTIFICATE. THIS FEE INCLUDES ONE CERTIFIED COPY OF THE NEW
				  RECORD. MAKE CHECK OR MONEY ORDER PAYABLE TO THE ILLINOIS DEPARTMENT OF PUBLIC
				  HEALTH. ADDITIONAL COPIES OF THE SAME RECORD ORDERED AT THE SAME TIME ARE $2.00
				  EACH.
Encl.
VR 170 (5-87r)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION K - Surrendered Person Registration Identification Form

Current through Register Vol. 48, No. 28, July 12, 2024
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___________________________________
(signature of surrendered
							 person)
______________________________
___________________________________
(date)
(printed or typed name of surrendered
							 person)
Illinois Department of Public Health, Division of Vital
				  Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.3 (rev.
				  05/2000)Printed by Authority of the State of
				  Illinois P.O. # 30M 02/00
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION L - Non-Surrendered Birth Sibling Registration Identification Form

Current through Register Vol. 48, No. 28, July 12, 2024
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___________________________________
(signature of non-surrendered birth
							 sibling)
___________________________
___________________________________
(date)
(printed or typed name of
							 non-surrendered birth sibling)
Illinois Department of Public Health, Division of
							 Vital Records, 605 W. Jefferson St., Springfield IL 62702-5097
VR 161.6 (rev. 05/2000)
Printed by Authority of the State of Illinois P.O. #
							 30M 02/00
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION M - Adoptive Parent Registration Identification Form

Current through Register Vol. 48, No. 28, July 12, 2024
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_______________________________
(signature of adoptive parent)
___________________________
________________________________
(date)
(printed or typed name of adoptive
							 parent)
Illinois Department of Public Health, Division of
							 Vital Records, 605 W. Jefferson St., Springfield IL 62702-5097
VR 161.4 (rev. 05/2000)
Printed by Authority of the State of Illinois P.O. #
							 30M 02/00
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix E - Adoption Records › ILLUSTRATION N - Legal Guardian Registration Identification Form

Current through Register Vol. 48, No. 28, July 12, 2024
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____________________________
(signature of legal guardian)
____________________________
____________________________
(date)
(printed or typed name of legal
							 guardian)
Illinois Department of Public Health, Division of
							 Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.5 (rev. 05/2000)
Printed by Authority of the State of Illinois P.O. #
							 30M 02/00
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix G - Death Records › ILLUSTRATION A - Report of Death

Current through Register Vol. 48, No. 28, July 12, 2024
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INSTRUCTIONS TO FUNERAL
				  DIRECTORS
1. In every case a
				Report of Death must be mailed (or otherwise filed with) the Registrar of the
				District in which death occurred within 24 hours of taking possession of the
				body.
2. If the body is to be
				cremated, shipped out of state or is a Coroner/Medical Examiner case, a permit
				signed by the Registrar must be obtained prior to final disposal of the
				remains.
3. A corrected death
				certificate must be filed with the Registrar where the death occurred in order
				to receive a signed permit as required in (2) above. In all other cases a
				completed death certificate must be filed with the Registrar where the death
				occurred within seven (7) days from the date of death.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix G - Death Records › ILLUSTRATION B - Necropsy (NEC)1

Current through Register Vol. 48, No. 28, July 12, 2024
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INSTRUCTIONS:
1. Prepare this form in triplicate. Use typewriter
							 for all entries except signature.
2. Sign original and first copy in pen and
							 ink.
3. Mail original and first copy to the coroner.
							 Retain last copy.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix G - Death Records › ILLUSTRATION D - Coroner's or Medical Examiner's Permit to Cremate a Dead Human Body

Current through Register Vol. 48, No. 28, July 12, 2024
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Being sufficiently informed as to the causes and
				  circumstances of the death of the above described decedent, permission is
				  hereby granted to cremate the body as requested.
Date____________________ (Signed)___________________, Medical
				  Examiner / Coroner
(MEDICAL EXAMINER CORONER - WHITE) (CREMATORIUM -
				  CANARY) (REGISTRAR - PINK) (FUNERAL DIRECTOR - GOLD)
VR-204.1 (8/89r)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix H - Affidavits › ILLUSTRATION A - Affidavit by Mother

Current through Register Vol. 48, No. 28, July 12, 2024
STATE OF ILLINOIS
DEPARTMENT OF PUBLIC
				  HEALTH
DIVISION OF VITAL RECORDS
SPRINGFIELD 62702-5097
NOTE:
A CERTIFIED COPY OF YOUR MARRIAGE RECORD
				  MUST ACCOMPANY THE COMPLETED AFFIDAVITS. AFFIDAVITS MUST BE SIGNED BEFORE A
				  NOTARY PUBLIC OR THEY WILL NOT BE ACCEPTED.
AFFIDAVIT BY MOTHER
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Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix H - Affidavits › ILLUSTRATION B - Affidavit by Father

Current through Register Vol. 48, No. 28, July 12, 2024
STATE OF ILLINOIS
DEPARTMENT OF PUBLIC
				  HEALTH
DIVISION OF VITAL RECORDS
SPRINGFIELD 62702-5097
NOTE:
A CERTIFIED COPY OF YOUR MARRIAGE RECORD
				  MUST ACCOMPANY THE COMPLETED AFFIDAVITS. AFFIDAVITS MUST BE SIGNED BEFORE A
				  NOTARY PUBLIC OR THEY WILL NOT BE ACCEPTED.
AFFIDAVIT BY FATHER:
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Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix H - Affidavits › ILLUSTRATION D - Abstract of a Record

Current through Register Vol. 48, No. 28, July 12, 2024
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This record states the following concerning the person named
				  above.
(Here copy the EXACT WORDING of the record which relates to
				  (1) the name of the child, (2) the date of birth, (3) the place of birth, (4)
				  the father's name, (5) the mother's maiden name.)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
COMMENTS ON CHANGES OR ERASURES:
_____________________________________________________________
_____________________________________________________________
I hereby certify that I have examined the record above
				  described; that it contains the entries above set forth; that there is
				  apparently no erasure or amendment of the birth or other essential information
				  except as explained above; and that the appearance of the paper and ink of said
				  record indicates that the entries were made at least _____ years ago.
Date
______________________
Signed
_______________________
(SEAL)
Title
_________________________
Address
_______________________
VR - 154e
State of Illinois - Department of Public Health -
							 Bureau of Vital Records
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 500 - ILLINOIS VITAL RECORDS CODE › Appendix I - Subregistrar's Appointment Blank

Current through Register Vol. 48, No. 28, July 12, 2024
SUBREGISTRAR'S APPOINTMENT
						  BLANK
I,
_________________________________________________
, Local Registrar of Registration District
No.
_____________________
County, Illinois, hereby request the State
						  Registrar
of Vital Records to approve my appointment of the
						  individual listed below as Subregistrar of Subregistration District No.
						  ___________ , effective ______________ ,19 ______ .
Miss
Mrs.
Mr.
___________________________________
__________________________
(Name of
						  Subregistrar)
(Local Title, if any, i.e., City
						  Clerk)
Subregistration Office Address
___________________________________
______________________________
, Illinois
_______
(Zip Code)
Telephone Numbers: Office
_________
Residence
_________
Area Code
_____
The area in which I authorize this Subregistrar to
						  serve is:
Anywhere within my Local Registration District.
Restricted to these areas:
______________________________________
___________________________________________________________________
Signed:
_________________
, Local Registrar___
Address:
______________________________
Dated:
_______
, 19
____
_________
, Illinois
______
(Zip Code)
APPROVED this
____
day of
____
, 19
____
____________________________________
, M.D.
Director, Illinois Department of
						  Public Health; and State Registrar of Vital Records, Springfield,
						  Illinois
NOTE:
Local Registrar should fill in and submit this
						  form in triplicate to the Office of Vital Records, Illinois Department of
						  Public Health, Springfield, Illinois, 62761. If the appointment is approved,
						  the Department will retain one copy and return two to the Local Registrar, one
						  for his files and one for the Subregistrar. An engraved certificate will also
						  be sent the Local Registrar to present to the Subregistrar.
VR 303 (2/75)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Section 505.10 - Statutes Referenced

Current through Register Vol. 48, No. 28, July 12, 2024
The following Illinois statutes are referenced in this
				Part:
a) Illinois Abortion Law of 1975
			 [720 ILCS 510 ]
b) Illinois Medical
			 Practice Act of 1987 [225 ILCS 60 ]
c) Freedom of Information Act [5 ILCS 140
			 ]
d) Medical Studies Act
			 [735 ILCS
			 5/8-2101 ]
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Section 505.30 - Definitions

Current through Register Vol. 48, No. 28, July 12, 2024
"Aggregate data" means a compilation of the data received by
				the Department on Induced Termination of Pregnancy Reports or Reports of
				Subsequent Complications after an Induced Termination of Pregnancy for each
				data set listed, except that the following will not be included:
Facility name;
Patient's identification number;
Physician's license number;
Any set of information for which the amount is so small (e.g.,
				50 or fewer) that identity of any person or persons to whom it relates may be
				discerned;
Education; and
Race and ethnicity.
"Complications" means those complications resulting from an
				abortion which, according to contemporary medical standards, are manifested by
				symptoms with severity equal to or greater than hemorrhaging requiring
				transfusion, infection, incomplete abortion, or punctured organs. (Section 10.1
				of the Law)
"Department" means the Department of Public Health, State of
				Illinois. (Section 2 of the Law)
"Director" means the Director, or his or her designee, of the
				Department of Public Health, State of Illinois.
"Law" means the Illinois Abortion Law of 1975.
"Patient identifying information" means any information or
				collection or grouping of data from which the identity of the person to whom it
				relates may be discerned.
"Physician" means any person licensed to practice medicine in
				all its branches under the Illinois Medical Practice Act of 1987. (Section 2 of
				the Law)
"Pregnancy termination" means the use of any instrument,
				medicine, drug or other substance or any device to terminate the pregnancy of a
				woman known to be pregnant with an intention other than to increase the
				probability of a live birth, to preserve the life or health of the child after
				live birth, or to remove a dead fetus. (Section 2 of the Law)
"Public Use File" means a computer file of aggregate
				data.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Section 505.40 - Submission of Information

Current through Register Vol. 48, No. 28, July 12, 2024
a) A
			 report of each abortion performed shall be made to the Department on forms
			 prescribed. The report forms shall not identify the patient by name, but by an
			 individual number to be noted in the patient's permanent record in the
			 possession of the physician. (Section 10 of the Act)
b) A report of each diagnosis of a
			 complication resulting from an abortion shall be made to the Department on
			 forms prescribed.
c) The Induced
			 Termination of Pregnancy Report consists of one form prescribed and promulgated
			 by the Department as Appendix B of this Part. The Department will provide this
			 form.
d) All Induced Termination of
			 Pregnancy Reports shall be submitted to the Department not later than 10 days
			 following the end of the month in which the pregnancy termination was
			 performed. (Section 10 of the Law)
e) The Report of Subsequent Complications
			 after an Induced Termination of Pregnancy consists of one form prescribed and
			 promulgated by the Department as Appendix C of this Part. The Department will
			 provide this form.
f) The Report of
			 Subsequent Complications after an Induced Termination of Pregnancy shall be
			 submitted to the Department within 10 days after the complications become known
			 by any physician who diagnoses a woman as having complications resulting from
			 an abortion. (Section 10.1 of the Law)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Section 505.50 - Availability of Information

Current through Register Vol. 48, No. 28, July 12, 2024
a) All
			 Reports of Induced Pregnancy Termination and Reports of Subsequent
			 Complications after an Induced Termination of Pregnancy will be treated as
			 confidential and are exempt from the Freedom of Information Act.
b) The Department will compile the
			 information contained in the Reports of Induced Pregnancy Termination and issue
			 reports of aggregate data as it deems necessary.
c) The Department will compile a Public Use
			 File upon request. Any person or entity making a request shall pay the cost of
			 producing the Public Use File. If a Public Use File has already been produced
			 and paid for, each succeeding requestor shall pay only the cost of duplicating
			 it.
d) Data compiled from the
			 Reports of Induced Pregnancy Termination and Reports of Subsequent
			 Complications after an Induced Termination of Pregnancy, other than the Public
			 Use Files, will not be released outside the Department.
e) The Department will disclose individual
			 patient or facility information only to the physician who originally supplied
			 that information to the Department, upon written request of the
			 physician.
f) The patient
			 identifying information submitted to the Department by those entities required
			 to submit information under the Law and this Part is to be used in the course
			 of medical study under the Medical Studies Act. Therefore, the information is
			 not admissible as evidence or discoverable in any action of any kind, in any
			 court or before any tribunal, board, agency or person.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Section 505.60 - Reporting Complications Resulting from Termination of Pregnancy

Current through Register Vol. 48, No. 28, July 12, 2024
a) Any physician
			 who diagnoses a woman as having complications resulting from an abortion shall
			 report, within the time period specified in this Section, the diagnosis and a
			 summary of her physical symptoms to the Department in accordance with this
			 Section.
b) Complications resulting
			 from an abortion are those which, according to contemporary medical standards,
			 are manifested by symptoms with severity equal to or greater than hemorrhaging
			 requiring transfusion, infection, incomplete abortion, or punctured organs.
			 (Section 10.1 of the Law)
c) If the
			 patient with complications returns to the facility where the induced
			 termination of pregnancy took place, the facility shall use the same patient
			 identification number used in the Induced Termination of Pregnancy Report when
			 updating the original Induced Termination of Pregnancy Report or completing a
			 Report of Subsequent Complications after an Induced Termination of Pregnancy
			 form.
d) If the patient with
			 complications selects a different medical facility, the physician making the
			 diagnosis shall complete the Report of Subsequent Complications after an
			 Induced Termination of Pregnancy form. The physician completing the Report of
			 Subsequent Complications after an Induced Termination of Pregnancy in such
			 circumstances shall not identify the patient by name, but shall create an
			 individual identification number for that patient to be noted in the patient's
			 permanent record in possession of the physician. If the name or location of the
			 facility where the abortion was performed is known, the physician shall include
			 it on the form. (Section 10.1 of the Law)
e) The Report of Subsequent Complications
			 after an Induced Termination of Pregnancy form shall be submitted to the
			 Department within 10 days after the diagnosis of the complication.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Appendix B - Induced Termination of Pregnancy Report

Current through Register Vol. 48, No. 28, July 12, 2024
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))
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
a. PATIENT'S RESIDENT STATE (See State Code
				table)
b. COUNTY (See County Code table)
c. ZIP CODE (Chicago only)
6. RACE/ETHNICITY
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)
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)
LIVE BIRTHS
a. NOW LIVING (Number)
b. NOW DEAD (Number)
OTHER TERMINATIONS
a. SPONTANEOUS (Number)
b. INDUCED (Number) (Do not include this
				termination)
13. Rh DETERMINATION (Not done/Rh Pos/Rh Neg)
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
a. PROCEDURE THAT TERMINATED PREGNANCY (check only
				one)
Antiprogestins (such as Mifepristone)
Suction Curettage
Sharp Curettage
Dilation and Evacuation (D & E)
Intra-Uterine Saline Instillation
Intra-Prostaglandin Instillation
Hysterotomy
Hysterectomy
Other (Specify)
b. ADDITIONAL PROCEDURES USED FOR THIS TERMINATION,
				IF ANY
17. COMPLICATIONS OF PREGNANCY
				TERMINATION?YN (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
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 505 - PREGNANCY TERMINATION REPORT CODE › Appendix C - Report of Subsequent Complications after an Induced Termination of Pregnancy

Current through Register Vol. 48, No. 28, July 12, 2024
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))
1. FACILITY NAME AND ADDRESS WHERE COMPLICATION WAS
				DIAGNOSED
2. PATIENT IDENTIFICATION NUMBER
3. REPORTING PHYSICIAN'S IDFPR LICENSE NUMBER
4. PATIENT INFORMATION
a. PATIENT'S RESIDENT STATE (See State Code
				table)
b. COUNTY (See County Code table)
c. ZIP CODE (Chicago only)
5. RACE/ETHNICITY
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)
b. Hispanic Origin
No, not Spanish/Hispanic/Latina
Mexican, Mexican American, Chicana
Puerto Rican
Cuban
Other Spanish/Hispanic/Latina
6. AGE LAST BIRTHDAY
7. MARRIED/CIVIL UNION?
8. DATE OF PREGNANCY TERMINATION
				(Mo/Day/Year)
9. COMPLICATIONS OF PREGNANCY TERMINATION (check all
				that apply)
Hemorrhage
Uterine Perforation
Anesthesia
Retained Products
Cervical Laceration
Infection
Death
Other (Specify)
10. HOSPITAL ADMISSION REQUIRED ON DATE OF
				EXAMINATION?
YN
11. FACILITY NAME OR LOCATION (IF KNOWN) WHERE THE
				ABORTION WAS PERFORMED
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.125 - Incorporated and Referenced Materials

Current through Register Vol. 48, No. 28, July 12, 2024
a) The following regulations and standards
				are incorporated in this Part:
1) Private and
				professional association standards:
A) Glasgow
				Coma Scale
Champion HR, Sacco WJ, Carnazzo AJ et al.:
CritCare Med 9(9): 672-676 (1981)
B) Revised Trauma Score, 1999 from Resources
				for the Optimal Care of the Injured Patient
American College of Surgeons
633 North Saint Clair Street
Chicago IL 60611-3211
C) Abbreviated Injury Score, 2005
American Association for the Advancement of Automotive
				  Medicine
Des Plaines IL 60008
D) Injury Severity Score
Baker SP, O'Neil B, Hadon W et al.:
Journal of Trauma 14: 187-196 (1974)
E) International Classification of Diseases,
9th Revision, Clinical
				  Modification (ICD-9-CM)
Alphabetic Index to External Causes of Injury
				  (E-Codes),
Second Printing (2010)
World Health Organization, Geneva, Switzerland and
National Center for Health Statistics
Published by Edwards Brothers, Inc. Ann Arbor MI
F) Resources for Optimal Care of
				the Injured Patient (2006)
American College of Surgeons
633 North Saint Clair Street
Chicago IL 60611-3211
G) Pediatric Advanced Life Support (PALS)
				(2011)
American Heart Association National Center
7272 Greenville Center
Dallas TX 75231
H) Advanced Cardiovascular Life Support
				(ACLS) Provider Manual (2010)
American Heart Association National Center
7272 Greenville Center
Dallas TX 75231
I) Pediatric Education for Prehospital
				Professionals (PEPP) Third Edition Provider Manual (2015)
American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village IL 60007
J) International Trauma Life Support (ITLS)
				8th Edition Provider Manual
ITLS-International Trauma Life Support
3000 Woodcreek Drive, Suite 200
Downers Grove IL 60515
K) Prehospital Trauma Life Support (PHTLS)
				8th Edition Providers Manual
National Association of Emergency Medical Technicians
				  (NAEMT)
P.O. Box 1400
Clinton MS 39060-1400
L) National Registry of Emergency Medical
				Technicians (NREMT) (2015): A nationally recognized corporation that certifies
				EMS Personnel:
https://www.nremt.org/nremt/about/apply_for_assess_exam.asp
M) National Registry of Emergency Medical
				Technicians (NREMT) Cognitive Exam Retest Policy (2015):
https://www.nremt.org/nremt/about/policyCognitiveExamRetest.asp
N) National EMS Scope of Practice Model
				(2007): National Highway Traffic Safety Administration (NHTSA):
http://www.ems.gov/education/EMSScope.pdf
O) National Association of EMS State
				Officials (NASEMSO), National Model EMS Clinical Guidelines (2014):
				https://www.nasemso.org/Projects/ModelEMSClinicalGuidelines/index.asp
P) National Guidelines for Educating EMS
				Instructors (2002), National Association of EMS Educators (NAEMSE):
http://naemse.org/?page=LVL1InstructorCourse
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.150 - Waiver Provisions

Current through Register Vol. 48, No. 28, July 12, 2024
a)
The Department may grant a waiver to any provision of
				the
Act or
this Part
for a specified period of
				time determined appropriate by the Department. The Department may grant a
				waiver when it can be demonstrated that there will be no reduction in standards
				of medical care as determined by the EMS
MD
or the
				Department.
(Section 3.185 of the Act) Waivers shall be valid only for
				the length of time determined by the Department (see subsection (f)). For
				either a single or multiple waiver request, the burden of proof as to the
				factual basis supporting any waiver shall be on the applicant.
b)
Any entity may apply in writing to
				the Department for a waiver to specific requirements or standards for which it
				considers compliance to be a hardship.
(Section 3.185 of the Act) The
				application shall contain the following information:
1) The applicant's name, address, and license
				number (if applicable);
2) The
				Section of the Act or this Part for which the waiver is being sought;
3) An explanation of why the applicant
				considers compliance with the Section to be a unique hardship, including:
A) A description of how the applicant has
				attempted to comply with the Section;
B) The reasons for non-compliance;
				and
C) A detailed plan for
				achieving compliance. The detailed plan shall include specific
				timetables;
4) The
				period of time for which the waiver is being sought;
5) An explanation of how the waiver will not
				reduce the quality of medical care established by the Act and this Part;
				and
6) If the applicant is a System
				Participant, the applicant's EMS MD shall state in writing whether he or she
				recommends or opposes the application for waiver, the reason for the
				recommendation or opposition, and how the waiver will or will not reduce the
				quality of medical care established by the Act and this Part. The applicant
				shall submit the EMS MD's statements along with the application for waiver. If
				the EMS MD does not provide written statements within 30 days after the
				applicant's request, the EMS MD will be determined to be in support of the
				application, and the application may be submitted to the Department.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.160 - Facility, System and Equipment Violations, Hearings and Fines

Current through Register Vol. 48, No. 28, July 12, 2024
a) Except for
				emergency suspension orders, or actions initiated pursuant to Sections
				3.117(a), 3.117(b), and
				3.90(b)(10)
				of the Act, prior to initiating an action for suspension, revocations, denial,
				nonrenewal, or imposition of a fine, for facility, system and equipment
				violations, the Department shall:
1) Issue a
				Notice of Violation which specifies the Department's allegations of
				noncompliance and requests a plan of correction to be submitted within 10 days
				after receipt of the Notice of Violation;
2) Review and approve or reject the plan of
				correction. If the Department rejects the plan of correction, it shall send
				notice of the rejection and the reason for the rejection. The party shall have
				10 days after receipt of the notice of rejection in which to submit a modified
				plan;
3) Impose a plan of
				correction if a modified plan is not submitted in a timely manner or if the
				modified plan is rejected by the Department;
4) Issue a Notice of Intent to fine, suspend,
				revoke, nonrenew or deny if the party has failed to comply with the imposed
				plan of correction, and provide the party with an opportunity to request an
				administrative hearing. The Notice of Intent shall be effected by certified
				mail or by personal service, shall set forth the particular reasons for the
				proposed action, and shall provide the party with 15 days in which to request a
				hearing. (Section
				3.130
				of the Act)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.165 - Suspension, Revocation and Denial of Licensure

Current through Register Vol. 48, No. 28, July 12, 2024
In accordance with Section
				  515.160,
				  the Director, after providing notice and an opportunity for an administrative
				  hearing to the applicant or licensee, shall suspend, revoke or refuse to issue
				  or renew the license of any licensee where the preponderance of the evidence
				  shows one or more of the following:
a)
				The licensee has not met continuing education or relicensure requirements as
				prescribed by the Department in this Part (Section
				3.50(d)(8)(A)
				 of the Act);
b) The licensee has failed to maintain
				proficiency in the level of skills for which he or she is licensed (Section
				3.50(b)(8)(B)
				 of the Act);
c) The licensee, during the provision of
				medical services, engaged in dishonorable, unethical or unprofessional conduct
				of a character likely to deceive, defraud or harm the public (Section
				3.50(d)(8)(C)
				 of the Act) (e.g., use of alcohol or illegal
				drugs while on duty, verbal or physical abuse of a patient, or
				misrepresentation of licensure status);
d) The licensee has failed to maintain or has
				violated standards of performance and conduct as prescribed by the Department
				in this Part or his or her EMS System's Program Plan (Section
				3.50(d)(8)(D)
				 of the Act);
e) The licensee is physically impaired to the
				extent that he or she cannot physically perform the skills and functions for
				which he or she is licensed, as verified by a physician, unless the person is
				on inactive status pursuant to this Part (Section
				3.50(d)(8)(E)
				 of the Act);
f) The licensee is mentally impaired to the
				extent that he or she cannot exercise the appropriate judgment, skill and
				safety for performing the functions for which he or she is licensed, as
				verified by a physician, unless the person ison inactive status pursuant to
				this Part (Section
				3.50(d)(8)(F)
				 of the Act);
g) The licensee has violated the Act or this
				Part (Section
				3.50(d)(8)(G)
				 of the Act);
h) The licensee has been convicted (or
				entered a plea of guilty or nolo contendere) by a court of competent
				jurisdiction of a Class X, Class 1, or Class 2 felony in this State or an
				out-of-state equivalent offense (Section
				3.50(d)(8)(H)
				 of the Act);
i) The licensee has demonstrated medical
				misconduct or incompetence, or a pattern of continued or repeated medical
				misconduct or incompetence, in the provision of emergency care; or
j) The licensee's license has been revoked,
				denied or suspended by the Department.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.170 - Employer Responsibility

Current through Register Vol. 48, No. 28, July 12, 2024
a) No
				employer shall permit any employee to perform any services for which a license,
				certificate, or other authorization is required under the Act, unless the
				employer first makes a good faith attempt to verify that the employee possesses
				all necessary and valid licenses, certificates, and authorizations required
				under the Act. (Section 3.160(a-5) of the Act)
b) Any person or entity that employs or
				supervises a person's activities as a First Responder or Emergency Medical
				Dispatcher shall cooperate with the Department's efforts to monitor and enforce
				compliance by those individuals with the requirements of the Act or this Part.
				(Section 3.160(b) of the Act)
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart A - GENERAL PROVISIONS › Section 515.180 - Administrative Hearings

Current through Register Vol. 48, No. 28, July 12, 2024
a)
				Administrative hearings shall be conducted by the Director or by an individual
				designated by the Director as Administrative Law Judge to conduct the hearing.
				On the basis of any such hearing, or upon default of the Respondent, the
				Director shall issue a Final Order specifying his or her findings of fact and
				conclusions of law and decision. A copy of the Final Order shall be sent to the
				Respondent or his or her attorney of record by certified mail or served
				personally upon the Respondent. (Section 3.135(a) of the Act)
b) The procedure governing hearings
				authorized by the Act shall be in accordance with Practice and Procedure in
				Administrative Hearings (77 Ill. Adm. Code 100) (Section 3.135(b) of the
				Act).
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart B - EMS REGIONS › Section 515.200 - Emergency Medical Services Regions

Current through Register Vol. 48, No. 28, July 12, 2024
Effective September 1, 1995, Emergency Medical Services
				  Regions are designated as follows:
a)
				Region 1 is the following counties:
Jo Daviess, Stephenson, Winnebago, Boone, Ogle, Lee, Carroll,
				  Whiteside, Dekalb.
b)
				Region 2 is the following counties:
Rock Island, Warren, Bureau, Putnam, LaSalle, Mercer, Henry,
				  Stark, Marshall, Livingston, Henderson, Knox, Peoria, Woodford, McDonough,
				  Fulton, Tazewell, McLean.
c) Region 3 is the following counties:
Hancock, Adams, Pike, Calhoun, Schuyler, Brown, Cass, Morgan,
				  Scott, Greene, Jersey, Mason, Menard, Sangamon, Macoupin, Logan, Christian,
				  Montgomery.
d) Region 4 is
				the following counties:
Madison, St. Clair, Monroe, Randolph, Bond, Clinton,
				  Washington.
e) Region 5 is
				the following counties:
Perry, Jackson, Union, Alexander, Marion, Jefferson,
				  Franklin, Williamson, Johnson, Pulaski, Wayne, Hamilton, Saline, Pope, Massac,
				  Edwards, White, Gallatin, Hardin, Wabash.
f) Region 6 is the following counties:
Ford, Iroquois, DeWitt, Piatt, Champaign, Vermilion, Macon,
				  Moultrie, Douglas, Edgar, Shelby, Coles, Cumberland, Clark, Fayette, Effingham,
				  Jasper, Crawford, Clay, Richland, Lawrence.
g) Region 7 boundary lines:
1) North - Illinois Route 71 east from the
				Kendall/LaSalle county line to Illinois Route 126; east on Illinois Route 126
				to the Kendall/Will county line; north on the Kendall/Will county line to the
				Will/DuPage county line; the Will/DuPage county line east to Naperville Road;
				Naperville Road South to I55; I55 north to Route 83 (Illinois Route 83 is in
				Region 8); Illinois Route 83 south to junction with Illinois Route 171 (Archer
				Avenue) (Illinois Route 171 is in Region 8); Illinois Route 171 north to the
				city limits of Summit; north along the Summit city limits to the Chicago city
				limits (Summit is in Region 7); south along the Chicago city limits to the
				Indiana/Illinois State line.
2)
				South - Grundy/Livingston county line; Kankakee/Livingston, Kankakee/Ford, and
				Kankakee/Iroquois county lines.
3)
				East - Illinois/Indiana state line for Cook, Will, and Kankakee
				counties.
4) West - Kendall/LaSalle
				county line from Route 71 south to Grundy/LaSalle county line; Grundy/LaSalle
				county line.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart B - EMS REGIONS › Section 515.220 - EMS Regional Plan Content

Current through Register Vol. 48, No. 28, July 12, 2024
a)
The EMS Medical Directors Committee
portion of the Regional
				Plan
shall address at least the following
(Section
				3.30(a)
				of the Act)
:
1)
Protocols for inter-System/inter-Region patient transports,
				including
protocols for pediatric patients and pediatric patients with
				special health care needs,
identifying the conditions of emergency
				patients
that
may not be transported to the different levels
				of emergency department, based on
the emergency
department
				classifications and relevant Regional considerations (e.g., transport times and
				distances);
2)
Regional standing medical orders;
3)
Patient transfer patterns,
				including criteria for determining whether a patient needs the specialized
				service of a trauma center, along with protocols for the bypassing of or
				diversion to any hospital, trauma center or regional trauma center,
Comprehensive Stroke Center
, Primary Stroke Center,
Acute
				Stroke-Ready Hospital
or Emergent Stroke Ready Hospital, which are
				consistent with individual System bypass or diversion protocols and protocols
				for patient choice or refusal;
4)
Protocols for resolving regional
				or inter-System conflict;
5)
An EMS disaster preparedness plan
				which includes the actions and responsibilities of all EMS
				participants
within
the Region
for
				care and transport of both the adult and pediatric population;
6)
Regional standardization of CE
				requirements;
7)
Regional standardization of Do Not Resuscitate (DNR)
and
				Practitioner Orders for Life-Sustaining Treatment (POLST)
policies, and
				protocols for power of attorney for health care;
8)
Protocols for disbursement of
				Department grants
(Section 3.30(a)(1-8) of the Act);
9)
Protocols for the triage,
				treatment, and transport of possible acute stroke patients
developed
				jointly with the Regional Stroke Advisory Subcommittee (Section
				3.30(a)(9)
				of the Act). Regional Stroke Data will be considered as it becomes available
				regarding development of stroke transport protocols;
10)
Regional standing medical
				orders
shall include
the administration of opioid
				antagonists.
(Section
				3.30(a)(10)
				of the Act);
11) Protocols for
				stroke screening;
12) Development
				of protocols to improve and integrate EMS for children (or EMSC) into the
				current delivery of emergency services within the Region; and
13) Development of a policy in regard to
				incidents involving school buses, which shall include, but not be limited to:
A) Assessment of the incident, including
				mechanism and extent of damage to the vehicle;
B) Passenger assessment/extent of
				injuries;
C) A provision for
				transporting all children with special healthcare needs and those with
				communication difficulties;
D) Age
				specific issues; and
E) Use of a
				release form for non-transports.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart B - EMS REGIONS › Section 515.230 - Resolution of Disputes Concerning the EMS Regional Plan

Current through Register Vol. 48, No. 28, July 12, 2024
a) If the EMS Medical Director's Committee
				and the Region's Trauma Center Medical Directors or Trauma Center Medical
				Director's Committee, whichever is applicable, have an unresolved dispute over
				the content of the Regional Plan, the following shall be sent to the Director:
1) All relevant information surrounding the
				issue being disputed.
2) A
				statement from the EMS Medical Director's Committee supporting their position;
				and the name, phone number and address of one person who should be contacted if
				further information is needed.
3) A
				statement from the Region's Trauma Center Medical Director or Trauma Center
				Medical Director's Committee, whichever is applicable, supporting their
				position; and the name, phone number and address of one person who should be
				contacted if further information is needed.
Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 515 - EMERGENCY MEDICAL SERVICES, TRAUMA CENTER, COMPREHENSIVE STROKE CENTER, PRIMARY STROKE CENTER AND ACUTE STROKE READY HOSPITAL CODE › Subpart B - EMS REGIONS › Section 515.240 - Bioterrorism Grants

Current through Register Vol. 48, No. 28, July 12, 2024
The Department shall distribute grant funds from the federal
				  Health Resources Services Administration (HRSA) to hospitals that apply for
				  these grants. All hospitals regardless of whether they receive HRSA funds are
				  required to meet the appropriate tier level classification, participate in the
				  Department's bioterrorism preparedness activities and comply with DPH rules.
				  Each hospital shall use the grant funds to meet minimum requirements for
				  bioterrorism in one of the following tiers. Requirements are listed in order of
				  priority. Grant applications shall indicate the level of participation and the
				  anticipated amount of funds needed for compliance. Grants will be awarded based
				  on factors, including, but not limited to, tier level of participation;
				  community and population served; EMS and trauma center designation in
				  accordance with this Part; availability of other sources of funding; and
				  resources utilized (e.g., number of ambulance providers and EMT training
				  programs).
a) Tier Level III -
				Participating Hospitals
1) Designate a
				contact person for disaster preparedness.
2) Have internet access in the emergency
				department utilizing a computer with at least Pentium 2, high speed internet
				access of minimum 384 KbPS, Internet Explore 5.5. or greater, to use
				Department-approved software for emergency department resources and hospital
				status.
3) Participate in disaster
				planning and disaster drills on a regional basis.
4) Have reference information on treatment of
				biological agents on site or post phone number of Illinois Poison Center
				(IPC).
5) Agree to implement
				System-Wide Crisis Policy and State Emergency Medical Disaster Plan and provide
				ongoing education to staff on both.
6) Have functional medical emergency radio
				communication of Illinois (MERCI) radio.
7) Develop a plan to identify, receive and
				distribute the National Pharmaceutical Stockpile and/or the State
				Pharmaceutical Stockpile to hospital staff.
8) Make training in the recognition and
				treatment of weapons of mass destruction available to the hospital
				staff.
9) Maintain disaster bags
				and supplies as outlined in the State Emergency Medical Disaster
				Plan.