{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-1-738k","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-1-738k","heading":"Posting of Individual Abortion Form - Notice - Sample","body":"form.\n\nA. Subsections B and C of this section shall become operative\n\non the later of:\n\n1. April 1, 2012; or\n\n2. Thirty (30) calendar days following the date on which the\n\nState Department of Health posts on its website the Individual\n\nAbortion Form and instructions concerning its electronic submission\n\nreferenced in this section.\n\nB. The Department shall post the Individual Abortion Form and\n\ninstructions concerning its electronic submission on its stable\n\nInternet website. Nothing in the Individual Abortion Form shall\n\ncontain the name, address, hometown, county of residence, or any\n\nother information specifically identifying any patient. The\n\nDepartment's Individual Abortion Form shall be substantially similar\n\nto, but need not be in the specific format, provided in subsection F\n\nof this section.\n\nC. Any physician performing abortions shall fully complete and\n\nsubmit, electronically, an Individual Abortion Form to the State\n\nDepartment of Health by the last business day of the calendar month\n\nfollowing the month in which the physician performs an abortion, for\n\neach abortion the physician performs.\n\nD. In cases in which a physician or the agent of a physician:\n\n1. Mails the printed materials described in Section 1-738.3 of\n\nthis title to a female specifically to comply with division (1) of\n\nsubparagraph d of paragraph 2 of subsection B of Section 1-738.2 of\n\nthis title;\n\n2. Gives or mails the printed materials described in Section 1-\n\n738.10 of this title to a female specifically to comply with\n\nsubsection A of Section 1-738.8 of this title; or\n\n3. Provides notice to a parent in compliance with Section 1-\n\n740.2 of this title,\n\nbut does not subsequently perform an abortion on the female or\n\nminor, the physician shall electronically submit a completed\n\nIndividual Abortion Form to the State Department of Health, and\n\nshall mark as \"not applicable\" those items of information that may\n\naccurately be provided only when an abortion is performed. The\n\nphysician shall not submit such a form if the physician knows that\n\nan abortion was subsequently performed on the female or minor by\n\nanother physician. Individual Abortion Forms required by this\n\nsubsection shall be submitted by the last business day of the second\n\ncalendar month following the calendar month in which the physician\n\nmails the printed materials or provides notice to a parent.\n\nE. The Individual Abortion Form shall contain a notice\n\ncontaining an assurance that, in accordance with subsection F of\n\nSection 1-738m of this title, public reports based on the form\n\nsubmitted will not contain the name, address, hometown, county of\n\nresidence, or any other identifying information of any individual\n\nfemale, that the State Department of Health will take care to ensure\n\nthat none of the information included in its public reports could\n\nreasonably lead to the identification of any individual female about\n\nwhom information is reported in accordance with the Statistical\n\nAbortion Reporting Act or of any physician providing information in\n\naccordance with the Statistical Abortion Reporting Act, and that\n\nsuch information is not subject to the Oklahoma Open Records Act.\n\nF. Individual Abortion Form. The Department's Individual\n\nAbortion Form shall be substantially similar to, but need not be in\n\nthe specific format of, the following form:\n\nIndividual Abortion Form\n\n(TO BE COMPLETED FOR EACH ABORTION PERFORMED)\n\n1. Date of abortion: _________________\n\n2. County in which the abortion was performed: ________________\n\n3. Age of mother: _________________\n\n4. Marital status of mother: ________________\n\n(specify married, divorced, separated, widowed, or never\n\nmarried)\n\n5. Race of mother: ________________\n\n6. Years of education of mother: ________________\n\n(specify highest year completed)\n\n7. State or foreign country of residence of\n\nmother:______________\nunty in which the abortion was performed: ________________\n\n3. Age of mother: _________________\n\n4. Marital status of mother: ________________\n\n(specify married, divorced, separated, widowed, or never\n\nmarried)\n\n5. Race of mother: ________________\n\n6. Years of education of mother: ________________\n\n(specify highest year completed)\n\n7. State or foreign country of residence of\n\nmother:______________\n\n8. Total number of previous pregnancies of the\n\nmother:___________\n\nLive Births: _________________\n\nMiscarriages: _________________\n\nInduced Abortions: __________________\n\n9. Approximate gestational age in weeks, as measured from the\n\nlast menstrual period of the mother, of the unborn child subject to\n\nabortion: _______________________________\n\n10. Method of abortion used:\n\nSuction Aspiration: ___________\n\nDilation and Curettage: ___________\n\nRU 486: ___________\n\nMethotrexate: ___________\n\nOther drug/chemical/medicine (specify): _________________\n\nDilation and Evacuation: ___________\n\nSaline: ___________\n\nUrea: ___________\n\nProstaglandins: ___________\n\nPartial Birth Abortion: __________\n\nHysterotomy: ___________\n\nOther (specify): ___________\n\n11. Was there an infant born alive as a result of the abortion?\n\n__________\n\nIf yes:\n\nWere life-sustaining measures undertaken? ___________\n\nHow long did the infant survive? ___________\n\n12. Was anesthesia administered to mother? ____________\n\nIf yes, what type? ____________________________\n\n13. Was anesthesia administered to the fetus? ___________\n\nIf yes:\n\nWhat type? _______________________\n\nHow was it administered? _______________________\n\n14. Method of fetal tissue disposal: _______________________\n\n15. Unless a medical emergency, as defined in Section 1-738.1A,\n\nor as applicable, Section 1-745.2 of Title 63 of the Oklahoma\n\nStatutes, exists, the abortion provider or agent shall ask the\n\npregnant female to provide, orally or in writing, the reason(s) she\n\nis seeking the abortion. If such a medical emergency exists, the\n\nabortion provider or agent shall specify on the form the condition\n\nwhich necessitated the immediate abortion: ___________________\n\nREASON GIVEN FOR ABORTION (check all applicable):\n\nHaving a baby:\n\nWould dramatically change the life of the mother: _________\n\nWould interfere with the education of the mother: _________\n\nWould interfere with the job/employment/career of the\n\nmother: ______\n\nMother has other children or dependents: ________\n\nMother cannot afford the child: ______\n\nMother is unmarried: ________\n\nMother is a student or planning to be a student: ________\n\nMother cannot afford child care: _______\n\nMother cannot afford the basic needs of life: ________\n\nMother is unemployed: _________\n\nMother cannot leave job to care for a baby: _________\n\nMother would have to find a new place to live: _________\n\nMother does not have enough support from a husband or partner:\n\n_____\n\nHusband or partner is unemployed: _______\n\nMother is currently or temporarily on welfare or public\n\nassistance: _________\n\nMother does not want to be a single mother: _______\n\nMother is having relationship problems: ________\n\nMother is not certain of relationship with the father of the\n\nchild: ________\n\nPartner and mother are unable to or do not want to get married:\n\n_______\n\nMother is not currently in a relationship: _______\n\nThe relationship or marriage of the mother may soon break up:\n\n_______\n\nHusband or partner is abusive to the mother or her children:\n\n_______\n\nMother has completed her childbearing: ________\n\nMother is not ready for a, or another, child: _______\n\nMother does not want people to know that she had sex or became\n\npregnant: ________\n\nMother does not feel mature enough to raise a, or another,\n\nchild: _______\n\nHusband or partner wants mother to have an abortion: ______\n\nThere may be possible problem affecting the health of the\n\nfetus: ________\n\nPhysical health of the mother is at risk: ________\nther is not ready for a, or another, child: _______\n\nMother does not want people to know that she had sex or became\n\npregnant: ________\n\nMother does not feel mature enough to raise a, or another,\n\nchild: _______\n\nHusband or partner wants mother to have an abortion: ______\n\nThere may be possible problem affecting the health of the\n\nfetus: ________\n\nPhysical health of the mother is at risk: ________\n\nParents want mother to have an abortion: _________\n\nEmotional health of the mother is at risk: ________\n\nMother suffered from a medical emergency as defined in Section\n\n1-738.1A of Title 63 of the Oklahoma Statutes: ______\n\nMother suffered from a medical emergency as defined in Section\n\n1-745.2 of Title 63 of the Oklahoma Statutes: _____\n\nMother wanted a child of a different sex: ______\n\nAbortion is necessary to avert the death of the mother: ______\n\nPregnancy was a result of forcible rape: ______\n\nPregnancy was a result of incest: ______\n\nOther (specify): ______\n\nPatient was asked why she is seeking an abortion, but she\n\ndeclined to give a reason: _______\n\n16. Method of payment (check one):\n\nPrivate insurance: _______\n\nPublic health plan: _______\n\nMedicaid: _______\n\nPrivate pay: _______\n\nOther (specify): _____________________________\n\n17. Type of private medical health insurance coverage, if any\n\n(check one):\n\nFee-for-service insurance company: ______\n\nManaged care company: ______\n\nOther (specify): _____________________________\n\n18. Sum of fee(s) collected: ___________\n\n19. Time of fee collection (check one):\n\nFull fee for abortion collected prior to or at the time the\n\npatient was provided the information required under subsection B of\n\nSection 1-738.2 of Title 63 of the Oklahoma Statutes: _________\n\nPartial fee for abortion collected prior to or at the time the\n\npatient was provided the information required under subsection B of\n\nSection 1-738.2 of Title 63 of the Oklahoma Statutes: _________\n\nFull fee for abortion collected at time the abortion was\n\nperformed: ________\n\nOther (specify): ________\n\n20. Specialty area of medicine of the physician: _____________\n\nAt which hospital(s) did the physician have hospital privileges\n\nat the time of the abortion?\n\n______________________________________________________________\n\n21. Was ultrasound equipment used before, during, or after the\n\nperformance of this abortion?\n\nBefore? _____ Vaginal, abdominal, or both? _____\n\nHow long prior to the abortion was the ultrasound performed?\n\n______\n\nWas the mother under the effect of anesthesia at the time of the\n\nultrasound? ______\n\nDuring? _____ Vaginal, abdominal, or both? _____\n\nAfter? _____ Vaginal, abdominal, or both? _____\n\nIf an ultrasound was performed, what was the gestational age of\n\nthe fetus at the time of the abortion, as determined by the\n\nultrasound? _____________\n\nAttach to this form a copy or screenshot of the ultrasound,\n\nintact with the date on which the ultrasound was performed, and with\n\nthe name of the mother redacted; provided, however, such ultrasound\n\nshall not be subject to an open records request and shall be subject\n\nto HIPAA regulations governing confidentiality and release of\n\nprivate medical records.\n\n21A. If an ultrasound was not performed prior to the abortion,\n\nwas the reason for not performing an ultrasound a medical emergency\n\nnecessitating an immediate abortion:\n\nTo avert death: _______\n\nTo avert substantial and irreversible impairment of a major\n\nbodily function arising from continued pregnancy: _______\n\nOther reason: ____________\n\n22. If ultrasound equipment was used, was the ultrasound\n\nperformed by:\n\nThe physician performing the abortion: _____\n\nA physician other than the physician performing the abortion:\n\n_____\n\nOther (specify): ___________________________\n\n23. Was the information required by paragraph 1 of subsection B\nnt of a major\n\nbodily function arising from continued pregnancy: _______\n\nOther reason: ____________\n\n22. If ultrasound equipment was used, was the ultrasound\n\nperformed by:\n\nThe physician performing the abortion: _____\n\nA physician other than the physician performing the abortion:\n\n_____\n\nOther (specify): ___________________________\n\n23. Was the information required by paragraph 1 of subsection B\n\nof Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to\n\nthe mother? ___________\n\na. If yes, was it provided:\n\nIn person: ___________\n\nBy telephone: ___________\n\nb. Was it provided by:\n\nA referring physician: __________\n\nThe physician performing the abortion: _________\n\nAn agent of a referring physician: ___________\n\nAn agent of the physician performing the abortion: ________\n\n24. Was the information required by paragraph 2 of subsection B\n\nof Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to\n\nthe mother? _________\n\na. If yes, was it provided:\n\nIn person: _______\n\nBy telephone: _______\n\nb. Was it provided by:\n\nA referring physician: _______\n\nAn agent of a referring physician: _______\n\nThe physician performing the abortion: ________\n\nAn agent of the physician performing the abortion: _______\n\n25. Did the mother avail herself of the opportunity to have the\n\nprinted materials described in Section 1-738.3 of Title 63 of the\n\nOklahoma Statutes mailed to her? ______________\n\n26. Were the informed consent requirements of subsection B of\n\nSection 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with\n\nbecause of a medical emergency necessitating an immediate abortion:\n\nTo avert death: ______\n\nTo avert substantial and irreversible impairment of a major\n\nbodily function arising from continued pregnancy: _____\n\n27. Was a determination of probable postfertilization age made\n\nas required by Section 1-745.5 of Title 63 of the Oklahoma Statutes?\n\n________\n\na. If no, was the determination of probable\n\npostfertilization age dispensed with:\n\nTo avert death: ________\n\nTo avert substantial and irreversible impairment of a\n\nmajor bodily function arising from continued\n\npregnancy: _____\n\nb. If yes, what was the probable postfertilization age?\n\n____\n\nWhat was the method and basis of the determination?\n\n_____\n\nWhat was the basis for the determination to perform\n\nthe abortion:\n\nTo avert death: _____\n\nTo avert substantial and irreversible impairment of a\n\nmajor bodily function arising from continued\n\npregnancy: ____\n\nWas the method of abortion used one that, in\n\nreasonable medical judgment, provided the best\n\nopportunity for the unborn child to survive? _____\n\nIf yes, was there an infant born alive as a result of\n\nthe abortion? _____\n\nIf no, what was the basis of the determination? _____\n\n28. Was the abortion performed within the scope of employment\n\nof an Oklahoma state employee or an employee of an agency or\n\npolitical subdivision of the state? ________\n\n29. Was the abortion performed with the use of any public\n\ninstitution, public facility, public equipment, or other physical\n\nasset owned, leased, or controlled by this state, its agencies, or\n\npolitical subdivisions? _________\n\n30. If the answer to question 28 or 29 is yes:\n\na. Was the abortion necessary to save the life of the\n\nmother? _______\n\nIf yes, what was the life-endangering condition?\n\n__________\n\nb. Did the pregnancy result from an act of forcible rape?\n\n_______\n\nIf yes, list the law enforcement authority to which\n\nthe rape was reported: ___________________\n\nList the date of the report: ___________\n\nc. Did the pregnancy result from an act of incest\n\ncommitted against a minor? _________\n\nIf yes, list the law enforcement authority to which\n\nthe perpetrator was reported: ________________\n\nList the date of the report: ___________\n\nTHIS PORTION TO BE COMPLETED IN CASE OF MINOR\n\n31. Minor's age at the time the abortion was performed:\nth and Safety Page 350\n\nList the date of the report: ___________\n\nc. Did the pregnancy result from an act of incest\n\ncommitted against a minor? _________\n\nIf yes, list the law enforcement authority to which\n\nthe perpetrator was reported: ________________\n\nList the date of the report: ___________\n\nTHIS PORTION TO BE COMPLETED IN CASE OF MINOR\n\n31. Minor's age at the time the abortion was performed:\n\n___________\n\n32. Was a parent of the minor provided notice prior to the\n\nabortion as described in Section 1-740.2 of Title 63 of the Oklahoma\n\nStatutes? ________\n\na. If yes, how was the notice provided?\n\nIn person: _______\n\nBy mail: _______\n\nb. If yes, to the best of the reporting physician's\n\nknowledge and belief, did the minor go on to obtain\n\nthe abortion? ________\n\n33. Was informed written consent of one parent obtained as\n\ndescribed in Section 1-740.2 of Title 63 of the Oklahoma Statutes?\n\n______\n\nIf yes, how was it secured?\n\nIn person: ___________\n\nOther (specify): _________\n\n34. If no notice was provided nor consent obtained, indicate\n\nwhich of the following apply:\n\nMinor was emancipated: ___________\n\nAbortion was necessary to prevent the death of the minor: _____\n\nMedical emergency, as defined in Section 1-738.1A of Title 63 of\n\nthe Oklahoma Statutes, existed: ___________\n\nMinor received judicial authorization to obtain abortion without\n\nparental notice or consent: ___________\n\n35. If no notice was provided nor consent obtained because a\n\nmedical emergency existed, indicate:\n\nWhether parent was subsequently notified (state period of time\n\nelapsed before notice was given): ____________\n\nWhether judicial waiver of notice requirement was obtained:\n\n________\n\n36. If the minor received judicial authorization to obtain an\n\nabortion without parental notice or consent, indicate which of the\n\nfollowing applies:\n\nJudge ruled that minor was mature enough to give informed\n\nconsent on her own: ___________\n\nJudge ruled that abortion was in the best interest of the\n\nminor: ___________\n\n37. If the female was a minor at the time of conception,\n\nindicate the age of the father of the unborn child at the time of\n\nconception: ________\n\n38. If at the time of conception the ages of the mother and\n\nfather were such that a violation of Section 1111, 1112, 1114 or\n\n1123 of Title 21 or Section 843.5 of Title 21 of the Oklahoma\n\nStatutes occurred, was the rape or abuse reported to the proper\n\nauthorities? ________\n\n39. Were the remains of the fetus after the abortion examined\n\nto ensure that all such remains were evacuated from the mother's\n\nbody? _________\n\nIf the remains of the fetus were examined after the abortion,\n\nwhat was the sex of the child, as determined from such examination?\n\n__________\n\nWas the sex of the child determined prior to the abortion?\n\n_________\n\nIf so, by whom? _______\n\nIf so, by what method? _____\n\nIf the sex of the child was determined prior to the abortion,\n\nwas the mother given information of the child's sex prior to the\n\nabortion? ________\n\n40. If the abortion was performed without surgery but rather as\n\nthe result of the administration of chemicals, was the physician\n\npresent in the same room as the woman to whom the chemicals were\n\nadministered at the time any such chemicals were first administered?\n\n_______\n\n4l. Prior to the pregnant woman giving informed consent to\n\nhaving any part of the abortion performed or induced, if the\n\npregnancy was at least eight (8) weeks after fertilization, was the\n\npregnant woman told that it may be possible to make the embryonic or\n\nfetal heartbeat of the unborn child audible for the pregnant woman\n\nto hear? _______\n\nWas the pregnant woman asked if she would like to hear the\n\nheartbeat? ______\n\nWas the embryonic or fetal heartbeat of the unborn child made\n\naudible for the pregnant woman to hear, using a Doppler fetal\n\nheart rate monitor? ______\n\nIf the response to any of the questions in this paragraph was\ne the embryonic or\n\nfetal heartbeat of the unborn child audible for the pregnant woman\n\nto hear? _______\n\nWas the pregnant woman asked if she would like to hear the\n\nheartbeat? ______\n\nWas the embryonic or fetal heartbeat of the unborn child made\n\naudible for the pregnant woman to hear, using a Doppler fetal\n\nheart rate monitor? ______\n\nIf the response to any of the questions in this paragraph was\n\nanything other than an unqualified YES, how was the abortion\n\nperformed in compliance with Sections 1-745.12 through 1-745.19\n\nof Title 63 of the Oklahoma Statutes? ________\n\nFiled this ____ day of __________, _____, by:\n\n______________________________\n\n(Name of physician)\n\n_____________________________\n\n(Physician's license number)\n\nNOTICE: In accordance with subsection F of Section 1-738m of Title\n\n63 of the Oklahoma Statutes, public reports based on this form will\n\nnot contain the name, address, hometown, county of residence, or any\n\nother identifying information of any individual female. The State\n\nDepartment of Health shall take care to ensure that none of the\n\ninformation included in its public reports could reasonably lead to\n\nthe identification of any individual female about whom information\n\nis reported or of any physician providing information in accordance\n\nwith the Statistical Abortion Reporting Act. Such information is\n\nnot subject to the Oklahoma Open Records Act.\n\nBe advised that any complication(s) shall be detailed in a\n\n\"Complications of Induced Abortion Report\" and submitted to the\n\nDepartment as soon as is practicable after the encounter with the\n\ninduced-abortion-related illness or injury, but in no case more than\n\nsixty (60) days after such an encounter.","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"a2e7848ac7e82fe7cbff5757dcf2f355a186df296e072a14f7c4d051d6fd34eb","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-1-738j","next":"us-ok/okla.-stat.-tit.-63-63-1-738l"},"notice":"GroundRules: Original legal text. Not legal advice."}