The Department of Health shall prepare a reporting form for physicians which shall provide for the collection of the following information:
(1)The number of pregnant mothers to whom the physician provided the information described in subdivision 34-23A-10.1 (1) and of those pregnant mothers, the number to whom the physician provided information in the capacity of a referring physician and the number to whom the physician provided information in the capacity of a physician who is to perform the abortion;
(2)The number of pregnant mothers to whom the physician provided the information described in subdivision 34-23A-10.1 (2); of that number, the number provided by telephone and the number provided in person; of each of those numbers, the number provided in the capacity of a referring
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The Department of Health shall prepare a reporting form for physicians which shall provide for the collection of the following information: (1) The number of pregnant mothers to whom the physician provided the information described in subdivision 34-23A-10.1 (1) and of those pregnant mothers, the number to whom the physician provided information in the capacity of a referring physician and the number to whom the physician provided information in the capacity of a physician who is to perform the abortion; (2) The number of pregnant mothers to whom the physician provided the information described in subdivision 34-23A-10.1 (2); of that number, the number provided by telephone and the number provided in person; of each of those numbers, the number provided in the capacity of a referring physician and the number provided in the capacity of a physician who is to perform the abortion; and of each of those numbers, the number provided by the physician and the number provided by an agent of the physician; (3) The number of pregnant mothers who availed themselves of the opportunity to obtain a copy of the printed information described in § 34-23A-10.3 , and the number who did not; and of each of those numbers, the number who, to the best of the reporting physician's information and belief, went on to obtain the abortion; (4) The number of pregnant mothers who availed themselves of the opportunity to view a sonogram image, hear the heartbeat of the unborn child, or both, pursuant to § 34-23A-52 , and the number who did not; and of each of those numbers, the number who, to the best of the reporting physician's information and belief, went on to obtain the abortion; (5) The number of abortions performed by the physician in which information otherwise required to be provided at least twenty-four hours before the abortion was not provided because an immediate abortion was necessary to avert the pregnant mother's death, and the number of abortions in which such information was not so provided because a delay would have created a serious risk of substantial and irreversible impairment of a major bodily function; (6) The name of the hospital or physician office; (7) The month, day, and year of the report; and (8) A unique patient number that can be used to link the report under this section to the medical report for inspection, clarification, and correction purposes, but which cannot, of itself, reasonably lead to the identification of any pregnant mother obtaining an abortion.