Application Form and Related Forms for the Operation of the National Death Index

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0215 National Death Index - Application Form	Form	Modified	Available
Form 0920-0215 National Death Index - Transmittal Form	Form	Modified	Available
Form 0920-0215 National Death Index- Request for Repeat Application Form	Form	Modified	Available
NDI 2013-2016 Sup St B 082213.docx	Supporting Statement B	Uploaded 2013-09-05	Available
NDI 2013-2016 Attach-F consult 082213.docx	Supplementary Document	Uploaded 2013-09-05	Available
NDI 2013-2016 Attach-G ERB 082313.pdf	Supplementary Document	Uploaded 2013-09-05	Available
NDI 2013-2016 Attach-E2 60-day comment 082213.docx	Supplementary Document	Uploaded 2013-09-05	Repair queued
NDI 2013-2016 Attach-E1 60day 082213.pdf	Supplementary Document	Uploaded 2013-09-05	Available
NDI 2013-2016 Attach-A Regs 082213.docx	Supplementary Document	Uploaded 2013-09-05	Repair queued
NDI 2013-2016 Sup St A 082213.docx	Supporting Statement A	Uploaded 2013-09-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6683	National Death Index - Application Form	Form	Modified
182824	National Death Index - Transmittal Form	Form	Modified
182823	National Death Index- Request for Repeat Application Form	Form	Modified

ICR Details

OMB Control No: 0920-0215	ICR Reference No: 201309-0920-006
Status: Historical Active	Previous ICR Reference No: 201010-0920-004
Agency/Subagency: HHS/CDC	Agency Tracking No: 20486
Title: Application Form and Related Forms for the Operation of the National Death Index
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/28/2013
	Date Received in OIRA: 09/16/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved	11/30/2013
Responses	240	0	240
Time Burden (Hours)	182	0	182
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC requests to extend data collection. Researchers apply to use the National Death Index (NDI) to determine whether persons in their studies have died and to obtain information on the decedents' states, dates of death, death certificate numbers, and causes of death. The administrative forms are completed by researchers in order to apply for NDI services and to submit their study subjects' records for computer matching against the NDI file.

---

Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 23764	04/22/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 55722	09/11/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
National Death Index - Application Form	0920-0215	National Death Index Application Form
National Death Index- Request for Repeat Application Form	0920-0215	Repeat Request for Application Form
National Death Index - Transmittal Form	0920-0215	Transmittal Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	240	240	0	0	0	0
Annual Time Burden (Hours)	182	182	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $50,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/16/2013

---