[YOUR MEDICAL CENTER NAME HERE]

DELINEATION OF PRIVILEGES IN ABORTION PROCEDURES
DEPARTMENT OF FAMILY MEDICINE

NAME:_____________________________________________   M.D./D.O.
                                                                          (Print)                                                                       (Circle One)

Family Physicians requesting privileges in abortion procedures need to meet the following requirements:

1. Current member of the Department of Family Medicine in good standing.
2. Documentation of training in abortion procedures by a recognized training program. Recognized are listed below.*
3. Maintaining these privileges requires providing the department with regular reports for the Departments Quality Improvement Program.

I. Manual Vacuum Aspiration (MVA)
Physicians requesting these privileges must provide documentation of a minimum of 50 MVAs.  Privileges for this procedure will be granted only after the physician has performed 2 successful procedures under the direct supervision of a physician designated  by this Department’s Chair.

II. Using Ultrasonography in the Assessment of Medication Abortions.
Physicians requesting this procedure must provide documentation of a minimum of 30 Ultrasound exams. These limited study sonograms need to include the dating of the first trimester of the pregnancy and follow up of early spontaneous or induced abortions. Physicians will be observed for the performance of a minimum of 2 sonograms by an appropriately designated physician. Granting this privilege is subject to the review of the Department Chair.

LIST OF PROCEDURES

___________________________________________________________________     ________________________
Signature of Family Physician                                                                                                 Date

___________________________________________________________________     ________________________
Signature ofSupervising Physician                                                                                          Date

___________________________________________________________________     ________________________
Signature of Chair of Department of Family Medicine                                                               Date

** Recognized training programs: