The Med.lcal Tep-:lix;.afi(i:n o_f. Pxegnancy kfil%;, :tl?75, are heréby repealed except as respects things done or omitted to'be done'before + such repeal. R G e o The Medical Tzrmnmuml of. Pngflnncy Rules, 2003 ’[PORM A - - ot [See sub-rule (2) of Rule 5} " - FORM ‘OF APPLICATION FOR THE APPROVAL' OF A PLACE UNDER CLAUSE (b) OF SECTION 4 OF THE ACT :
Category of appmved placv ' ey £ BT o <R Gynaecologlcal e)gmmanon or]ab unabl» " W Tilesuscltam:{\eqmp ent. 0 é terilisa equlpment . ur‘"flk Ll ah LT CATEGORYB il JPIE RS R T [
1. Substituted by Notification No. G.S.R 730(E) dated 12-10-2021, w.e.f. 1102021 A 4 Address rand o?:her dgs e:0f 1 O - FTEEITS BTG fi;&:’:f i i i .mmr‘mp BT : ” wow. fris [ i o f“éw M& ”"’"
(n) '% Jn». {n 4’:.‘ mmflafiafirrfim BiSY UL, [y ia‘:\sa:«\—*hf U@i | AEPE DRES e ST me'mfifim e ~Emfi$mrmfi;w Ergrdiie 1 102 . The Medical Termination of Pregnancy Rules, 2003 FORM C [See Rule 9] aged about.
.address) at present residing al consent to the termination of my pregnancy at..
name of place where the pregnancy is to be terminated) Place : e e e ~Date: e e _ ‘ixgnature (To be filled in by guardian where the woman is a mz’ntully ill person or minor) :
aged about. t present residing at (permanent address). reeerrveensedo héréby give my consent to the termination of the pregnancy of my ward................who is a minor/lunatic at .. (place of termination of pregnancy).
Place: - Date :
103 The Medical Termination of Pregnancy Rules, 2003 1[FORM D [See sub-clause (ii) of clause (b) of Rule 3A] REPORT OF THE MEDICAL BOARD FOR PREGNANCY TERMINATION BEYOND 24 WEEKS Details of the woman seeking termination of pregnancy :
1. Name of the woman
2. Age:
3. Registration/Case Number :
4. Available reports and investigations : .
5. No. Report =~ - | = ~~Opinion on the findings
5. . Additional Investigations (if done) : - B S. No. Investigations . - -Key findings i done - B % 6. ‘Opinion by Medical Board for termination of pregnancy :
{a) Allowed
(b) Denied “Justification for the decision :
7. Physical fitness of the woman for the termination of pregnancy :
. a Yes :
b. No Members of the Medical Board who reviewed the case :
S.No, Name - . Signature, Date and Time : .....
-
1. Inserted by Notification No. GS.R. 730(E) dated 12-10-2021, w.e.£. 12 -10-2021.
The Medical Termination of Prégriaricy Rules, 2003 1[FORM E . - Form f'R_‘e‘gxslered Medical Prachhoners ““(Forgestatmrl age beynmi twenty weeks hll twenly “foirr wecks) {Seé sug-'rule ) of Ru"le 4A] T hm'_;.tfw " -~ Opinioni opinidn, ormegn_jg'ts ‘lalth, lhal it is { mecessary to terminate. the pmgnancy of —— — resident of . . MR (Full address of pregnant woman in bfoéfi 1eners) which is bé'yé'n_("l' twerty weeks but till Mengfig)ur weeks under specnal circumstances as gwenbelow CIR- TR *Specify the Circimstance(s) gom fi 6 (g) 'apprupnate f’g-r {erminatioh of Ppregnancy beynnd twenty weeks till twenty-four weeks: 1§ &
(a) Su.rvxvors of sexual assault pr rape or mces oo b) NS E T FEBTE R B L e ¥ T et m(c)«éhange—uf’manta]*’—smus- uring (wxdowhood and divorce) ..
B ! «t}!e'-ongomg Ppregnancy 7
(d)_w,omen.wi _physical disabilities [major, disability.as per-criteria 4 laid down under the«nghtS of Persons with Disabilities Act, 2016 .
@95 2076)] [ovrecreoerrr B i O - - (e) Mentally ill women mduding}hental retardation " (f) “The foetal malformation_that has substantial. risk of being ‘incompatible with life or if the child is born it may suffer from such physical or mental abnormalities to be seriously handicapped
(g) Womén with pregnancy ‘in humanitarian settings or disaster or I . emergency situations as dedaxed by Government.
5.
1.+ Inséited b Notification No GSR. 730(5)fi,angduqmm,m}um.mzmn TS 105 The Medical Termination of Pregnancy Rulss, 2003 ° We hereby give intimation that we terminated the pregnancy of the woman referred to above who bears the Serial No. in the Admission Register of the hospnal/appwved place s i “. ' Signature of the Registered Medical Practitioner R et -y ngnalum of the Regls‘temd Medxcal I’ractmoner Place: v .
Date: ¥ L% U Tl s me AR T T Note ; Account may be taken of !he pregnant woman'’s actual.or. reasonably T foreseeable environment in detemumng whether the continuance of her pregnancy would " mvoIve a grave mjury to her physical or mental .mnh] s’r_u‘_ ma‘v rrvnrmfv.vmirfl Ww?mwwmwéfifimwfi BRI finj‘-,‘!':;fimyb mfihwmfify an'-fi"fir“‘)'“fi" V. -~ | (e GR35 ERA R R PR (b den) 11 Fnfrr TRR BT BiaS B OF § o BRER ) ® § iy FRW T 1 TR A Ehn esie (g) F RESTIORS TR AU T SRR s g e e vm)fims‘#fiw“wm»‘# i .
y: e umfimmm (:
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