Choice on Termination of Pregnancy Act, 1996 (Act No. 92 of 1996)RegulationsAnnexuresAnnexure B |
ANNEXURE B
CHOICE ON TERMINATION OF PREGNANCY ACT, 1996 (ACT NO. 92 OF 1996)
| I. | STATEMENT BY MINOR WHO REQUESTS THE TERMINATION FOR HER PREGNANCY |
I, the undersigned (surname and first names of minor) ......................................................
.............................................., hereby state that I have been advised by (surname and first names of medical practitioner/ registered midwife*) ........................................................... in terms of section 5 of the Act to consult with my parents, guardian, family members or friends before the termination of my pregnancy.
Signed ...............................................
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Date.....................................................
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* Delete what is not applicable
| II. | CONSENT TO THE TERMINATION OF THE PREGNANCY OF A WOMAN WHO IS SEVERELY MENTALLY DISABLED OR IN A STATE OF CONTINUOUS UNCONSCIOUSNESS |
Name of facility .................................................................................................................
| 1. | Intended termination of the pregnancy of (surname and first names of minor/major woman) ....................................................., born on .......................................... and having the identity number (where available) .............................................. and the facility/ hospital/ clinic number ........................................................................................... |
| 2. | I [surname and first names] .................................................................................. the undersigned, acting as the natural guardian / legal guardian / curator personae / spouse* of the abovementioned woman, hereby, in terms of section 5(4)(i) or (ii) of the Act request and consent to the termination of the pregnancy of (surname and first names of the abovementioned minor / major woman) ....................................................... , who is— |
| (a) | so severely mentally disabled that she is completely incapable of understanding and appreciating the nature or consequences of the termination of her pregnancy; or |
| (b) | in a state of continuous unconsciousness and has no reasonable prospect of regaining consciousness in time to request and to consent to the termination of her pregnancy in terms of section 2 of the Act. |
Signed ...............................................
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Date.....................................................
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Natural guardian/legal guardian/curator personae/spouse* refuses to consent.
CONSENT OF TWO MEDICAL PRACTITIONERS OR A MEDICAL PRACTITIONER AND A REGISTERED MIDWIFE
| 3. | I, ............................................................................................................., the undersigned, being a medical practitioner, and I, ..............................................................., the undersigned, being a medical practitioner / registered midwife who has completed the training course*, certify that we examined [surname and first names of abovementioned minor / major woman) ......................................................................... on (date). |
| 4. | In our opinion her pregnancy is within the first 20 weeks of the gestation period and*— |
| (a) | the continued pregnancy would pose a risk of injury to the woman's physical or mental health [section 2(1)(b)(i) of the Act]; |
| (b) | there is a substantial risk that the foetus would suffer from a severe physical or mental abnormality [section 2(1)(b)(ii) of the Act]; |
| (c) | the pregnancy resulted from rape or incest [section 2(1)(b)(iii) of the Act]; or |
| (d) | the continued pregnancy would significantly affect the social or economic circumstances of the woman [section 2(1)(b)(iv) of the Act]. |
| 5. | We consent to the termination of her pregnancy. |
(a) |
Signed
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Date
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Qualifications
................................................. |
Registration number
...................................... |
(b) |
Signed
.................................................. |
Date
...................................... |
Qualifications
................................................. |
Registration number
...................................... |
*Circle what is applicable.