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212A Title:TERMINATION OF PREGNANCY REGULATIONSGazette Number:
Schedule:Heading:SCHEDULEVersion Date:30/06/1997
Caution : This is a past version. See the current version for the latest position.

FORM 1
[regulation 3]

CONFIDENTIAL
Not to be destroyed within five years of the date of operation

OFFENCES AGAINST THE PERSON ORDINANCE
(Chapter 212)
CERTIFICATE TO BE COMPLETED IN RELATION TO THE TERMINATION
OF A PREGNANCY UNDER SECTION 47A(l) OF THE ORDINANCE
I, .........................................................................................................................
(Name and qualifications of practitioner in block capitals)

of ........................................................................................................................
(Full address of practitioner)

............................................................................................................................

and I, ...................................................................................................................
(Name and qualifications of practitioner in block capitals)

of ........................................................................................................................
(Full address of practitioner)

............................................................................................................................
hereby certify that we are of the opinion, formed in good faith, that in the
case of the pregnancy of ......................................................................................

............................................................................................................................
(Full name of pregnant woman in block capitals)

of ........................................................................................................................
(Usual place of residence of pregnant woman in block capitals)

............................................................................................................................
      1. the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated;
      2. the continuance of the pregnancy would involve risk of injury to the physical or mental health of the pregnant woman greater than if the pregnancy were terminated;
      3. there is a substantial risk that if the child were born, it would suffer from such physical or mental abnormality as to be seriously handicapped.
This certificate of opinion is given before the commencement of the treatment for the termination of the pregnancy to which it relates.

Signed ........................................... Date ................................................

Signed ........................................... Date ................................................
Note: For termination of a pregnancy in emergency under section 47A(4) and termination of a pregnancy of more than 24 weeks duration under section 47A(2C) of the Ordinance, use respectively Form 2 and Form 2A.		(Ring appropriate number)




(L.N. 50 of 1982; L.N. 66 of 1982)
_____________

FORM 2
[regulation 3]

CONFIDENTIAL
Not to be destroyed within five years of the date of operation

OFFENCES AGAINST THE PERSON ORDINANCE
(Chapter 212)
CERTIFICATE TO BE COMPLETED IN RELATION TO THE TERMINATION OF A
PREGNANCY IN EMERGENCY UNDER SECTION 47A(4) OF THE ORDINANCE
I, ........................................................................................................................
(Name and qualifications of practitioner in block capitals)

of .......................................................................................................................
(Full address of practitioner)

............................................................................................................................

and I, ...................................................................................................................
(Name and qualifications of practitioner in block capitals)

of .......................................................................................................................
(Full address of practitioner)
...........................................................................................................................

hereby certify that we are*/were* of the opinion, formed in good faith, that it is*/was* immediately necessary to terminate the pregnancy of ...............................

...........................................................................................................................
(Full name of pregnant woman in block capitals)

of .......................................................................................................................
(Usual place of residence of pregnant woman in block capitals)

............................................................................................................................

in order-
    1. to save the life of the pregnant woman; or

    2. to prevent grave permanent injury to the physical or mental health of the pregnant woman.
This certificate of opinion is given-
    A. before the commencement of the treatment for the termination of the pregnancy to which it relates;
      or, if that is not reasonably practicable, then

    B. not later than 24 hours after such termination.

Signed ......................................... Date ...............................................

Signed ......................................... Date ...............................................		(*Delete as approp-
riate)












(Ring appropriate number)





(Ring appropriate letter)
(L.N. 50 of 1982)
_____________

FORM 2A
[regulation 3]

CONFIDENTIAL
Not to be destroyed within five years of the date of operation

OFFENCES AGAINST THE PERSON ORDINANCE
(Chapter 212)

CERTIFICATE TO BE COMPLETED IN RELATION TO THE TERMINATION
OF A PREGNANCY OF MORE THAN 24 WEEKS DURATION UNDER
SECTION 47A(2C) OF THE ORDINANCE
I, ........................................................................................................................
(Name and qualifications of practitioner in block capitals)

of .......................................................................................................................
(Full address of practitioner)

............................................................................................................................

and I, ...................................................................................................................
(Name and qualifications of practitioner in block capitals)

of .......................................................................................................................
(Full address of practitioner)

...........................................................................................................................

hereby certify that we are*/were* of the opinion, formed in good faith, that it is*/was* necessary to terminate the pregnancy of ..................................................

...........................................................................................................................
(Full name of pregnant woman in block capitals)

of .......................................................................................................................
(Usual place of residence of pregnant woman in block capitals)

...........................................................................................................................

in order to save the life of the pregnant woman.

This certificate of opinion is given-
    A. before the commencement of the treatment for the termination of the pregnancy to which it relates;
      or, if that is not reasonably practicable, then

    B. not later than 24 hours after such termination.
Signed ......................................... Date ...............................................

Signed ......................................... Date ...............................................		(*Delete as approp-
riate)















(Ring appropriate letter)
(L.N. 50 of 1982)
_____________

FORM 3
[regulation 4]

CONFIDENTIAL
OFFENCES AGAINST THE PERSON ORDINANCE
(Chapter 212)

NOTIFICATION TO THE DIRECTOR OF HEALTH OF THE TERMINATION OF A PREGNANCY UNDER SECTION 47A OF THE ORDINANCE
I, ......................................................................................................................
(Name and qualifications of practitioner in block capitals)

of .....................................................................................................................
(Full address of practitioner)

.........................................................................................................................

hereby give notice that I terminated the pregnancy of ...........................................

.........................................................................................................................
(Full name of pregnant woman in block capitals)

of .....................................................................................................................
(Usual place of residence of pregnant woman in block capitals)

.........................................................................................................................

at .....................................................................................................................

on ..................................................... (date) at ....................................... (time).


The termination of the pregnancy was certified as necessary because-
    1. the continuance of the pregnancy would have involved risk to the life of the pregnant woman greater than if the pregnancy were terminated;

    2. the continuance of the pregnancy would have involved risk of injury to the physical or mental health of the pregnant woman greater than if the pregnancy were terminated;

    3. there was a substantial risk that if the child had been born, it would have suffered from such physical or mental abnormality as to be seriously handicapped.

IN CASE OF EMERGENCY where the termination of pregnancy is not carried out in a hospital or clinic maintained by the Crown or in an approved hospital or clinic

The termination of the pregnancy was certified as immediately necessary-
    1. to save the life of the pregnant woman; or

    2. to prevent grave permanent injury to the physical or mental health of the pregnant woman.

The circumstances giving rise to the emergency and relating to the termination of the pregnancy were-

.........................................................................................................................

.........................................................................................................................
(include details of the pregnant woman's medical condition)

IN CASE OF TERMINATION OF PREGNANCY OF MORE THAN 24 WEEKS DURATION

The termination of the pregnancy was certified as necessary to save the life of the pregnant woman.

The circumstances relating to the termination of the pregnancy were-

.........................................................................................................................

.........................................................................................................................
(Include details of the pregnant woman's medical condition)

Signature of practitioner who terminated pregnancy-

.........................................................................................................................

Particulars of certifying medical practitioners-
      A. Name ..............................................................................................
        Address ...........................................................................................
        ........................................................................................................

        Qualifications ...................................................................................





      B. Name ..............................................................................................
        Address ...........................................................................................

        ........................................................................................................

        Qualifications ...................................................................................







Other information relating to the termination of pregnancy-
    1. Maiden name of woman ..............................................

    2. Date of birth of woman ............................................

    3. Marital status of woman-
      (a) Single
      (b) Married
      (c) Widowed
      (d) Divorced or separated
      (e) Not known
    4. Occupation of woman ............................................................................

    5. Occupation of husband, if woman is married ............................................
      ..............................................................................................................

    6. Date of woman's last menstrual period ....................................................

    7. Previous pregnancies of woman-
      (a) Number of live-births .......................................................................
      (b) Number of still births ........................................................................
      (c) Number of pregnancies terminated ....................................................
      (d) If applicable, date of last termination of pregnancy under the Offences against the Person Ordinance-
        ........................................................................................................

    8. Number of woman's existing children ......................................................

    9. Date of admission to place of termination of pregnancy-
      ..............................................................................................................

    10. Date of discharge from place of termination of pregnancy-
      ..............................................................................................................
    11. Was the terminated pregnancy that of a woman impregnated before attaining the age of 16 years?
                      Yes No
      If "Yes", give an estimate of her age at the time of impregnation.
                      Estimate ................................................

    12. Was the terminated pregnancy that of a woman who had made a report to a police officer, that she had been the victim of an alleged offence under section 47 (which relates to incest), 118 (which relates to rape), 119 (which relates to intercourse procured by threats), 120 (which relates to intercourse procured by false pretences) or 121 (which relates to intercourse procured by drugs) of the Crimes Ordinance within a period not exceeding 3 months after the date upon which she alleged that any such offence was committed?
                      Yes No
      If "Yes", give the name of the alleged offence, the date that it was alleged to have been committed, the date and place of report to the police-
      (a) Name of alleged offence ..................................................................
      (b) Date of alleged offence ....................................................................
      (c) Date of report to police .....................................................................
      (d) Place of report to police ....................................................................
        ........................................................................................................

    13. Medical condition of woman-
      (a) Obstetric disease (specify) ................................................................
      (b) Non-obstetric disease (specify) .........................................................

    14. Type of termination of pregnancy-
      (a) Dilation and evacuation
      (b) Hysterotomy-abdominal
      (c) Hysterotomy-vaginal
      (d) Hysterectomy-abdominal
      (e) Hysterectomy-vaginal
      (f) Vacuum aspiration
      (g) Other (specify) ................................................................................

    15. Was sterilization performed?
                      Yes No

    16. Complications or death prior to notification-
      (a) None
      (b) Sepsis
      (c) Haemorrhage
      (d) Death
      (e) Other (specify) ................................................................................

    17. In the case of death, specify the cause-
      ..............................................................................................................
      ..............................................................................................................
      ..............................................................................................................
Note: This form is to be completed by the operating medical practitioner and sent in a sealed and confidential envelope not later than 3 days after the termination of the pregnancy to the Director of Health, Department of Health, Hysan Avenue, Hong Kong.		A.
(To be completed in all cases)

























B.
(To be completed in all cases Ring appropriate number)







C.
(To be completed only in emergency cases)



(Ring appropriate number)









D.
(To be completed only when pregnancy was more than 24 weeks)








E.
(To be completed in all cases)


If the operating medical practitioner joined in giving the certificate insert at A particulars of the other certifying medical practitioner


If the operating medical practitioner did not join in giving the certificate insert at A and B particulars of the two certifying medical practitioners

F.
(to be completed in all cases)





(Ring appropriate letter)




























(Ring appropriate answer)














(Ring appropriate answer)









(Ring appropriate letter)







(Ring appropriate answer)


(Ring appropriate letter)
(L.N. 50 of 1982; L.N. 76 of 1989; L.N. 107 of 1995)