National Death Index - Application Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0215 can be found here:

Documents and Forms

Document Name Document Type
National Death Index - Application Form Form
NDI Application Form Att B NDI Application Form 120816.docx Form

Information Collection (IC) Details

IC Title:	National Death Index - Application Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	NDI Application Form	Att B NDI Application Form 120816.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0166 Vital Statistics for Births, Deaths, Fetal Deaths, Marriages and Divorces Occurring in the US During Each Year	FR Citation: 49 FR 37695

Number of Respondents: 100	Number of Respondents for Small Entity: 5

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	0	50	50
Annual IC Time Burden (Hours)	450	100	225	125
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.