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pdfForm Approved
OMB No. 0920-0004
Exp. Date 6/30/2013
CDC Fax: 1 (800) 767 - 8542
CITY CODE:
WEEKLY MORTALITY REPORT
City:
City Code:
Age
Date of Report:
Total Deaths Including
Pneumonia and Influenza
Pneumonia
Influenza
Under 28 days
28 days to 1 Year
1 - 14
15 - 24
25 - 44
45 - 64
65 - 74
75 - 84
85 and over
Unknown
TOTAL
THE NUMBER OF DEATHS is the number of certificate received by your office during the reporting period, regardless of date of death. The count includes
all certificates of deaths occurring in your city regardless of the residence of the deceased. It does not include fetal deaths (stillbirths).
FAX YOUR REPORT TO CDC to 1 (800) 767 - 8542 at the close of work every day
Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection
Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0004).
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
| File Type | application/pdf |
| File Title | daily mortality form.xls |
| Author | acy9 |
| File Modified | 2010-10-27 |
| File Created | 2010-10-27 |