Health (Regulation of Termination of Pregnancy) Act 2018 (Applicationfor Review of Relevant Decision) Regulations S.I. No. 595/2018

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of 8th January, 2019.

I, SIMON HARRIS, Minister for Health, in exercise of the powers conferred on me by section 3 of the Health (Regulation of Termination of Pregnancy) Act 2018 (No. 31 of 2018), hereby make the following regulations:

1. (1) These Regulations may be cited as the Health (Regulation of Termination of Pregnancy) Act 2018 (Application for Review of Relevant Decision) Regulations 2018.

(2) These Regulations shall come into operation on 1 January 2019.

2. The form specified in the Schedule is prescribed for the purposes of Hsection 13 (2) of the Health (Regulation of Termination of Pregnancy) Act 2018 (No. 31 of 2018).

SCHEDULE

Health (Regulation of Termination of Pregnancy) Act 2018

Form to be completed in relation to an application under section 13 of the Health (Regulation of Termination of Pregnancy) Act 2018 for review of a relevant decision

Please complete this form in BLOCK CAPITALS.

Part 1 (a) — Applicant details

To be completed by the pregnant woman* where she is applying for a review of a relevant decision on her own behalf.

Name and contact details of Applicant

First name
Surname
Address
Mobile or landline telephone number (if available)
Email address (if available)
Date of birth
Please confirm that you are making this application on your own behalf

* Please sign this form at Part 4

Part 1 (b) — Applicant details and details of pregnant woman

To be completed by a person acting on behalf of a pregnant woman* in relation to an application for a review of a relevant decision.

Name and contact details of the pregnant woman concerned

First name
Surname
Address
Mobile or landline telephone number (if available)
Email address (if available)
Date of birth

Name and contact details of the person acting on behalf of the pregnant woman

First name
Surname
Address
Mobile or landline telephone number (if available)
Email address (if available)
Please indicate the basis on which you are acting on behalf of the pregnant woman(e.g. parent, guardian, spouse, friend, social worker, doctor etc)

* Please sign this form at Part 4

Part 2 — Details of medical practitioner(s) whose relevant decision(s) are the subject of the application

To be completed by the pregnant woman applying for review OR by the person acting on her behalf.

Medical practitioner 1

Name of medical practitioner
Address of medical practitioner
Medical specialty (if known)
Date consulted

Medical practitioner 2

Name of medical practitioner
Address of medical practitioner
Medical specialty (if known)
Date consulted

Part 3 — Further information

To be completed by the pregnant woman applying for review OR by the person acting on her behalf.

Name and contact details (if known) of the medical practitioner or hospital attended for maternity services (if any / if different from medical practitioners listed above)
Grounds on which termination of pregnancy is being sought (tick as appropriate)	□ Risk to life or health (section 9)□ Condition likely to lead to death of foetus (section 11)

Part 4 — Signature

Signature of person making application

Signed: .............................................................. Date: .............................................

GIVEN under my Official Seal,

21 December 2018.

SIMON HARRIS,

Minister for Health.

EXPLANATORY NOTE

(This note is not part of the instrument and does not purport to be a legal interpretation.)

These Regulations may be cited as the Health (Regulation of Termination of Pregnancy) Act 2018 (Application for Review of Relevant Decision) Regulations 2018.

These Regulations provide for a prescribed form to be used for the purpose of applying for a formal review of relevant decision under Section 13 of the Act.

Irish Statutory Instruments

S.I. No. 595/2018 - Health (Regulation of Termination of Pregnancy) Act 2018 (Applicationfor Review of Relevant Decision) Regulations 2018

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