The Department of Health and Human Services shall prescribe an abortion reporting form which shall be used for the reporting of every abortion performed in this state. Such form shall include the following items:
(1) The age of the pregnant woman;
(2) The location of the facility where the abortion was performed;
(3) The type of procedure performed;
(4) Complications, if any;
(5) The name of the attending physician;
(6) The pregnant woman's obstetrical history regarding previous pregnancies, abortions, and live births;
(7) The stated reason or reasons for which the abortion was requested;
(8) The state of the pregnant woman's legal residence;
(9) The length and weight of the aborted child, when measurable;
(10) Whether an emergency situation caused the physician to waive any of the requirements of section 28-327; and
(11) Such other information as may be prescribed in accordance with section 71-602.
The completed form shall be signed by the attending physician and sent to the department within fifteen days after each reporting month. The completed form shall be an original, typed or written legibly in durable ink, and shall not be deemed complete unless the omission of any item of information required shall have been disclosed or satisfactorily accounted for. Carbon copies shall not be acceptable. The abortion reporting form shall not include the name of the person upon whom the abortion was performed. The abortion reporting form shall be confidential and shall not be revealed except upon the order of a court of competent jurisdiction in a civil or criminal proceeding.