Medical Termination of Pregnancy Rules, 2003 - FORM A - Form of application for the approval of a place

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

 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)  Dugs 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