Form Acia-1522-196 - Certification Regarding Abortion - Iowa Department Of Human Services
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2Iowa Department of Human Services
Certification Regarding Abortion
Certify to one of the following:
I certify that on the basis of my professional judgment:
❏ Life of the mother
___________________________________________________________________________________________________
(Name and address of the mother)
suffers from a physical disorder, physical injury or physical illness, including a life-endangering physical condition caused or
arising from the pregnancy itself, that would place her in danger of death unless an abortion is performed.
❏ Fetus deformed
The fetus carried by ___________________________________________________________________________________
(Name and address of the mother)
is physically deformed, mentally deficient or afflicted with a congenital illness based on:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
(Medical indications)
❏ Rape
❏ Incest
I, _____________________________________________,
I, _____________________________________________,
(Name of official)
(Name of official)
of _____________________________________________
of _____________________________________________
(Name of agency)
(Name of agency)
received a signed form from _________________________
received a signed form from _________________________
(Name and address of person reporting)
(Name and address of person reporting)
stating that ____________________________________
stating that ____________________________________
(Name and address of the mother)
(Name and address of the mother)
was the victim of an incident of rape.
was the victim of an incident of incest.
The incident took place on __________________________
The incident took place on __________________________
(Date)
(Date)
and the incident was reported on _____________________.
and the incident was reported on _____________________.
(Date)
(Date)
The report included the name,
The report included the name,
address and signature of the person making the report.
address and signature of the person making the report.
I further certify that the mother has been given the opportunity to view an ultrasound image of the fetus as part of the standard
care before an abortion is performed, and the mother has been provided information regarding the options relative to a pregnancy
including continuing the pregnancy to term and retaining parental rights following the child’s birth, continuing the pregnancy to
term and placing the child for adoption, and terminating the pregnancy.
Signature of attending provider:
_________________________________________ Date:_____________________
Signature of official of law enforcement, public or private health agency which may include a family physician:
___________________________________________________________ Date:_____________________
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