Completed forms should be submitted to the ND Department of Health and Human Services. Mail the report to the Vital Records Unit at 600 East Boulevard Avenue, Dept 325, Bismarck, ND 58505-0250. Additionally, address any questions to the Vital Records Unit at 328-2360 for further assistance.

This report must be completed for each pregnancy termination occurring in North Dakota. Ensure the current year's reports are submitted by the specified deadlines as indicated by the Department of Health and Human Services.

The purpose of the Induced Termination of Pregnancy Data Report is to collect vital statistics on pregnancy terminations in North Dakota. This data is instrumental for public health officials to analyze trends and demographics related to reproductive health. Accurate documentation also supports healthcare providers in complying with state regulations.

• 1. Facility Name: Name or address of the facility where the procedure occurred.
• 2. City of Pregnancy Termination: City where the pregnancy termination took place.
• 3. County of Pregnancy Termination: County where the procedure was performed.
• 4. Patient's ID Number: Unique identifier for the patient.
• 5. Age Last Birthday: Patient's age at the time of termination.
• 6. Married?: Marital status of the patient.
• 7. Date of Pregnancy Termination: Date when the termination occurred.
• 8. Residence-State: State of the patient's residence.
• 9. County: County of residence.
• 10. City, Town, or Location: Specific city, town, or location of residence.
• 11. INSIDE City Limits?: Whether the residence is within city limits.
• 12. ZIP Code: ZIP Code of the patient's residence.
• 13. Ancestry: Specifies the patient's ancestry background.
• 14. Race: Identifies the patient's race.
• 15. Hispanic Origin: Indicates if the patient identifies as Hispanic.
• 16. EDUCATION: Educational attainment of the patient.
• 17. Date of Last Normal Menses Began: Last date patient had normal menstrual period.
• 18. Clinical Estimate of Gestation: Estimated weeks of gestation at the time of termination.
• 19. PREVIOUS PREGNANCIES: History of previous pregnancies and outcomes.
• 20. Termination Procedures: Details of procedures used for the termination.
• 21. Complications of Pregnancy Termination: Identifies any complications that occurred.
• 22. Adverse Events of Pregnancy Termination: Records any adverse events related to the procedure.
• 23. Reason for Procedure: Reason why the pregnancy was terminated.
• 24. Name of Attending Physician: Name of the physician overseeing the procedure.
• 25. Name of Person Completing Report: Name of the individual filling out the report.
• 26. Signature of Attending Physician: Signature of the attending physician.
• 27. Date: Date the report is completed.

Failing to submit this form can result in non-compliance with state regulations. This may lead to legal consequences for health providers. Accurate and prompt reporting is crucial for public health data integrity.

• Legal Consequences: Non-compliance may result in legal actions against the facility and responsible healthcare providers.
• Statistical Accuracy: Missing reports compromise the accuracy of public health statistics.
• Impact on Patient Care: Failure to document may affect future medical care and treatment plans.

• 1. Post-Procedure Documentation: To record details after a pregnancy termination procedure.
• 2. Statistical Reporting: For use in reporting vital statistics related to reproductive health.
• 3. Patient Record Keeping: As part of the patient's medical records for future reference.