FORM A - Form of application for the approval of a place under clause (b) of section 4 Category of approved place
( 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
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.
(ii) An operation table and Instruments for performing abdominal or gynaecological surgery.
(iii) Dugs and parental fluid in sufficient supply for emergency cases.
(iv) Anaesthetic equipment, resuscitation equipment and sterilization equipment.
Signature of the owner of the place
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