Appendix to Subpart F of Part 441 - Required Consent Form
42:4.0.1.1.10.6.100.11.1 :
Appendix to Subpart F of Part 441 - Required Consent Form
Notice: Your decision at any time not to be sterilized will not
result in the withdrawal or withholding of any benefits provided by
programs or projects receiving Federal funds.
consent to sterilization
I have asked for and received information about sterilization
from (doctor or clinic). When I first asked for the information, I
was told that the decision to be sterilized is completely up to me.
I was told that I could decide not to be sterilized. If I decide
not to be sterilized, my decision will not affect my right to
future care or treatment. I will not lose any help or benefits from
programs receiving Federal funds, such as A.F.D.C. or Medicaid that
I am now getting or for which I may become eligible.
I understand that the sterilization must be considered permanent
and not reversible. I have decided that I do not want to become
pregnant, bear children or father children.
I was told about those temporary methods of birth control that
are available and could be provided to me which will allow me to
bear or father a child in the future. I have rejected these
alternatives and chosen to be sterilized.
I understand that I will be sterilized by an operation known as
a ______. The discomforts, risks and benefits associated with the
operation have been explained to me. All my questions have been
answered to my satisfaction.
I understand that the operation will not be done until at least
30 days after I sign this form. I understand that I can change my
mind at any time and that my decision at any time not to be
sterilized will not result in the withholding of any benefits or
medical services provided by Federally funded programs.
I am at least 21 years of age and was born on (Day) (Month)
(Year).
I, ______, hereby consent of my own free will to be sterilized
by ______ by a method called ______. My consent expires 180 days
from the date of my signature below.
I also consent to the release of this form and other medical
records about the operation to:
Representatives of the Department of Health and Human Services
or
Employees of programs or projects funded by that Department but
only for determining if Federal laws were observed.
I have received a copy of this form. (Signature) (Date) (Month)
(Day) (Year).
You are requested to supply the following information, but it is
not required: (Race and ethnicity designation (please check)) Black
(not of Hispanic origin); Hispanic; Asian or Pacific Islander;
American Indian or Alaskan native; or White (not of Hispanic
origin).
interpreter's statement
If an interpreter is provided to assist the individual to be
sterilized:
I have translated the information and advice presented orally to
the individual to be sterilized by the person obtaining this
consent. I have also read him/her the consent form in ______ ______
language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
(Interpreter) (Date).
statement of person obtaining consent
Before (name of individual) signed the consent form, I explained
to him/her the nature of the sterilization operation ______, the
fact that it is intended to be a final and irreversible procedure
and the discomforts, risks and benefits associated with it.
I counseled the individual to be sterilized that alternative
methods of birth control are available which are temporary. I
explained that sterilization is different because it is
permanent.
I informed the individual to be sterilized that his/her consent
can be withdrawn at any time and that he/she will not lose any
health services or any benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be
sterilized is at least 21 years old and appears mentally competent.
He/She knowingly and voluntarily requested to be sterilized and
appears to understand the nature and consequence of the procedure.
(Signature of person obtaining consent) (Date) (Facility)
(Address).
physician's statement
Shortly before I performed a sterilization operation upon (Name
of individual to be sterilized) on (Date of sterilization)
(operation), I explained to him/her the nature of the sterilization
operation (specify type of operation), the fact that it is intended
to be a final and irreversible procedure and the discomforts, risks
and benefits associated with it.
I counseled the individual to be sterilized that alternative
methods of birth control are available which are temporary. I
explained that sterilization is different because it is
permanent.
I informed the individual to be sterilized that his/her consent
can be withdrawn at any time and that he/she will not lose any
health services or benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be
sterilized is at least 21 years old and appears mentally competent.
He/She knowingly and voluntarily requested to be sterilized and
appeared to understand the nature and consequences of the
procedure.
(Instructions for use of alternative final paragraphs:
Use the first paragraph below except in the case of premature
delivery or emergency abdominal surgery where the sterilization is
performed less than 30 days after the date of the individual's
signature on the consent form. In those cases, the second paragraph
below must be used. Cross out the paragraph which is not used.)
(1) At least 30 days have passed between the date of the
individual's signature on this consent form and the date the
sterilization was performed.
(2) This sterilization was performed less than 30 days but more
than 72 hours after the date of the individual's signature on this
consent form because of the following circumstances (check
applicable box and fill in information requested): Premature
delivery.
Individual's expected date of delivery: ______
☐ Emergency abdominal surgery: (describe circumstances):______
(Physician) (Date).