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Choice on Termination of Pregnancy Act, 1996 (Act No. 92 of 1996)

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Annexure A

 

ANNEXURE A

 

CHOICE ON TERMINATION OF PREGNANCY ACT, 1996 (ACT NO. 92 OF 1996)

 

NOTIFICATION OF TERMINATION OF PREGNANCY IN TERMS OF SECTION 7 OF THE ACT

 

FORM TO BE COMPLETED BY A MEDICAL PRACTITIONER OR A REGISTERED MIDWIFE

(To be completed in duplicate)

 

 

1. Name of facility ...............................................................................................................

 

2. Age of woman requesting termination .............................................................................

 

3. Where appropriate (encircle appropriate number);

 

3.1 Termination in terms of section 2(1)(a) or (b) of the Act.

 

3.2 Severe mental disability [section 5(4)(a) of the Act].

 

3.3 Continuous unconsciousness [section 5(4)(b) of the Act].

 

4. Race (mark with a cross):

African

Coloured

Asian

White

Other

 

If other, specify ................................................................................................................

 

5.        Marital status (mark with a cross):

Single

Living together

Married

Divorced

Widowed

 

6.        Date of last menstrual period (LMP) .................................................................................

 

7.        How many weeks into pregnancy? ....................................................................................

 

8.        Number of previous pregnancies:

No. of live births

No. of stillbirths

No. of terminations

No. of miscarriages

 

9.        Date of admission ............................................................................................................

 

Date of procedure ............................................................................................................

 

Date of discharge .............................................................................................................

 

10.        Termination of pregnancy (mark with a cross):

(a)        first 12 weeks

(b)        13-20 weeks

 

11. Indication for termination of pregnancy (applicable only to terminations performed from 13th up to and including 20th week of gestation period (circle appropriate number):

 

11.1        Woman's physical or mental health [section 2(1)(b)(i) of the Act].

 

11.2        Foetal physical or mental abnormality [section 2(1)(b)(ii) of the Act].

 

11.3        Rape or incest [section 2(1)(b)(iii) of the Act].

 

11.4        Social or economic circumstances [section 2(1)(b)(iv) of the Act].

 

Name of medical practitioner or registered midwife .........................................................

 

..........................................................................................................................................

 

Signed ...............................................

 

Date.....................................................

 

Qualifications .....................................

 

Registration number ............................