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Medical Termination of Pregnancy Regulations, 2003

FORM II - Custody of forms

[ See Regulation 4(5) ]

 1.      Name of the State

 2.      Name of the Hospital/approved place

 3.      Duration of pregnancy ( give total No. only )

                  (a)   Up to 12 weeks.

                  (b)   Between 12 - 20 weeks

4.      Religion of woman

                  (a)   Hindu

                  (b)   Muslim

                  (c)   Christian

                  (d)   Others

                  (e)     Total

 5.      Termination with acceptance of contraception.

                  (a)   Sterlisation.

                 (b)    I.U.D.

 6.      Reasons for termination :

( give total number under each sub-head )

                 (a)   Danger to life of the pregnant woman.

                 (b)   Grave injury to the physical health of the pregnant woman.

                 (c)   Grave injury to the mental health of the pregnant woman.

                 (d)   Pregnancy caused by rape.

                 (e)   Substantial risk that if the child was born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.

                  (f)   Failure of any contraceptive device or method.

 
 Signature of the Officer Incharge with Date

 

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