Affidavit Addendum

This addendum is for women who had an abortion in a state that has “A Woman’s Right to Know” or
informed consent law that mandates printed materials be provided or offered.. Many states have these
laws such as Alabama, Arkansas, Florida, Georgia, Idaho, Kansas, Louisiana, Michigan, Minnesota,
Mississippi, Nebraska, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota,
Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

1. Were you given written materials or a booklet concerning such things as the abortion
procedure, the physical and psychological risks of abortion, and fetal development?
 Yes  No Comments:

a. Were you given time to read the information before your abortion?  Yes  No
(Note: the amount of time required varies from state to state)
b. Did you read the materials?  Yes  No
c. Did you read the materials before or after your abortion?  Before  After

2. If you were a minor at the time of the abortion, were you told that a parent must be notified or
give consent?  Yes  No
a. Were you told that a judge could waive notification or consent?  Yes  No
b. Did you go before a judge to avoid notification or consent?  Yes  No

Comments:

3. Were you asked about your medical and psychological history?  Yes  No

4. Did you get a physical exam by the person performing the abortion?  Yes  No

5. Were lab tests done prior to the abortion?  Yes  No

6. Were you told how long you had been pregnant or given your due date?  Yes  No

7. Were you provided counseling?  Yes  No

a. By whom? (e.g., doctor, nurse, facility worker, counselor)
b. What were you told?

8. Did you discuss about your feelings about abortion?  Yes  No

9. Were your concerns addressed and questions answered?  Yes  No

a. By whom?

10. Did you sign a consent form for your abortion?  Yes  No

a. Was the consent form explained to you?  Yes  No

b. Did you read the form before signing it?  Yes  No

Print Name:

Signed: Dated: