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FORM
A
(
See sub-rule (2) of rule 5 )
Form of application for the approval
of a place under clause (b) of section 4
Category of approved place:
A Pregnancy can be terminated upto 12
weeks
B Pregnancy can be terminated upto 20
weeks
1. Name of the place ( in capital
letters )
2. Address in full
3. Non-Government/Private/Nursing
Home/Other Institutions
4. State, if the following facilities
are available at the place
Category A
i) Gynecological examination /
labour table.
ii) Resuscitation equipment.
iii) Sterilization equipment.
iv) Facilities for treatment of
shock, including emergency drugs.
v) Facilities for transportation,
if required.
Category B
(ii) An operation table and
Instruments for performing abdominal or gynaecological surgery.
(iii) Drugs and parental fluid in
sufficient supply for emergency cases.
(iv) Anaesthetic equipment,
resuscitation equipment and sterilization equipment.
Place :
Date :
Signature of the owner
of the place
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