Annexure-lll APPLICATIOM FOR STERILIZATION OPERATION AND CONSENT FORM 1. Name : Shri/Smt.___________________________________________________________________ 2. Husband's Name and address _________________________________________________________ 3. Father's Name and address____________________________________________________________ 4. Operation Centre____________________________________________________________________ Dear Sir, Madam, Kindly make arrangements for my sterilization operation. My age is _________years and my husband/wife's age is___________years. I am married and my husband/wife is alive. We have ______ male and _____female living children. The age of my youngest living child is______ years. I have decided to undergo sterilization operation independently and on my own without any outside pressure, inducement or force. I am aware that other methods of contraception are available to me. I know that for all practical purposes this operation is permanent and that, after the operation I will be unable to have any more children. I also know that there are still some chances of failure of the operation for which the hospital/institution and (Operating doctor will not be held responsible by me or my relative or any other person whomsoever. My husband/wife has not been sterilized previously. I am aware that I am undergoing operation which carries an element or risk. I have been explained the eligibility criteria for the operation and I affirm that I am eligible to undergo operation according to criteria. I agree to undergo the operation under any type of anesthesia, which the doctor think suitable for me and to be given other medicines as considered appropriate by the doctor concerned. If after the sterilization operation I get pregnant, then I shall report within two weeks to the doctor/hospital and will get abortion done at free of cost. Under such circumstances, the State Government will pay a compensation of Rs.50.00 to me which will be acceptable to me. I know that if 1 am unable to get the pregnancy aborted within two weeks, then I will not be entitled to claim any compensation from any court of law in this regard. I agree to come for follow up to the centre/doctor as instructed, failing which, I shall be responsible for the consequences, if any. I have read the above mentioned facts/information in my own language. Religion : __________________ Age :___________________ Education Qualification : ___________________ Business/Occupation : ___________________ Signature of the acceptor/applicant Signature of the witness : ___________________ Full name _______________________________ Full address :_______________________________ (Only for those beneficiaries who can not read and write) Shri/Smt. ______________________ has been explained other methods of contraception available and the failures associated with other methods have been explained fully. Signature of Counselors. Full Name_________________________________ Full Address _______________________________ I know very well Shri/Smt.___________________________ and the information given by me/her is correct. His/her name has been registered with health centre/city centre at Sr.No._____________________ Signature of ________________________ Full Name __________________________ Full Address ________________________ I certify that! have satisfied myself that Shri/Smt.____________________is within the eligible age group and is mentally and medically fit for a sterilization operation. There is no evidence that he/she has undergone a sterilization operation previously. I have explained all clauses to the client and that this form has the authority of a legal documents. Signature of operating doctor Signature of medical officer (Name and address) (Name and address) Denial of sterilization I certify that Shri/Smt. ________________________________________________________is not suitable client for re sterilization/sterilization for the following reasons. 1. _____________________________________________________________________________________ 2. _____________________________________________________________________________________ He/she has been provided the following alternative methods of contraception. Signature of counselor ** or Doctor making decision. 3. District Place of Surgery & Date__________ 1. Male Registration SI.Number in the 2. Name of the Head of the Register of relevant centre/ Family Hospital__________________ Shri__________________ (d) Name of Father/Husband 4. Mohalla House No. ______________________ 5. P.H.C./Urban centre ______________ 6. Ward ______________________________ 7. Religion _______________________ 8. Caste/general/SC/ST/BW Class _________________________________ 9. Whether married Yes/No 10.Age of applicant (complete years) ________________________________________ 11. Age of Husband/wife(complete Years ____________________ 12. Number of alive children 13.Age at first marriage (a) Sons (b) Daughters Age___________ Month_______________ Husband ____________ Wife______________ 14 Educational Qualifications Husband - illiterate/literate/primary/ junior high School/High School/Graduate and above. Wife - illiterate/literate/primary/junior High School/High School/Graduate and above. 15. Difference from the last Termination of Pregnancy (Delivery or abortion) ______________years_______________and_____________________ Payment particular: Note:- Complete particular of different recipients of the amount after sterilization operation. Account particular will be prepared and kept separately. Amount given to applicant Rupees_____________Paise_______________ For ______________ of sterilization. Signature of applicant Date_______________ Name________________________ Person concerned with the service of the applicant: Name _____________________________________ ________________________________________ Post _______________________________________ Place of Appointment 1. Promoter __________________________ 2. Health Inspector _____________________ 3. Aneisthist ___________________________ 4. Surgeon ____________________________ If Tubectomy method adopted. (Name and address) Counsellor can be any health personnel including doctor. FOR OFFICIAL USE ONLY a) To be filled by Health examined/doctor Note:- If the surgeon is himself health examined, the certificate may be given by him. Age of the client according to appearance_____________________________________ Urine analysis for sugar___________________________________________________ Blood pressure __________________________________________________________ Whether client has gone sterilization earlier or not_______________________________ As per examination by the doctor, the client is mentally and medically fit for sterilization operation. I have confirmed from the client regarding his/her marital status and number of living children. I have explained pros and cons of the sterilization operation to the client and he himself is mentally ready for the operation. __________________ ____________________ Signature of the client Signature of the Surgeon _________________________________ _________________________________ (Name in capital Setters) (Name in capital Setters) Present place of Posting________________ (b) Certificate of the surgeon. Certificate of the Surgeon I have performed sterilization operation. During the operation there was no visible signs of earlier sterilization and as per appearance he/she was within the age limit for sterilization, if it is female sterilization, the type of operation performed. Abdominal/viganial/laparoscopic/mini lap/general/local anesthesia use. ________________________________ Signature of the Surgeon _________________________________ (Name in capital Letters) Present place of Posting________________ Economic, social and demographic details of the client undergoing sterilization operation. Monthly report of the District Family Welfare Bureau should be accompanied by the following proforma. a. Male/Female (a) Number of cases _________________ b. Rural/urban Village_________________________ c. The end of last pregnancy Serial No._______________________ delivery/abortion. Abdominal/Vaginal/Laproscopic/Laprotomy and General/local anaesthesia. Encircle the part this is applicable. Full name (clearly)_________________________ Present address ___________________________ ___________________________ 16. Whether any contraceptive method has been adopted earlier: Yes/No If yes i) Name of the method_____________________ ii) Period of the method ____________________ 17. Whether promotor of applicant is regional worker of family welfare programme Yes/No If yes, whether applicant is inhabitant of the jurisdiction of that Worker Yes/No 18. Reason for the application of sterilization: Limited family/diseases/ financial or other. I certify that above mentioned particular is correct. Signature____________________ Place __________________ Full Name_____________________ Present Address ____________________
