Health Centre /Clinic/Hospital

Abortion Care Tally Sheet

Region Zone/Subcity/Woreda Health Facility Name Begin Date End Date

 Abortion Care Tally Sheet
Woreda:__________________________ Facility: _______________
Year:__________________ Month:__________________
Safe abortion Post abortion care
Age
Total count
Category
10-14 Years 15-19 years 20-24 years 25-29 years + 30 years 10-14 Years 15-19 years 20-24 years 25-29 years + 30 years

First Tally
trimester
(<12 week)

Count

Second Tally
trimester
(>=12 weeks)

Count
Total