Att D_Current Approved Version

Attachment D

Currently Approved Version of Form

Form Approved/OMB No. 0920-0213

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 30 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 data. An agency may not collect 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 Reports Clearance Officer: 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN.: PRA 0920-0213)

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL CENTER FOR HEALTH STATISTICS

DIVISION OF VITAL STATISTICS

RESEARCH TRIANGLE PARK, NC 27709

ANNUAL VITAL STATISTICS OCCURRENCE REPORT

______________________________

Registration Area (State or County, State)

Submitted By ___________________________________Date ___________________

Title ___________________________________

Vital Statistics Events by Month of Occurrence: Calendar Year ex. 2011

MARRIAGES/ DIVORCES /ANNULMENTS

January

February

March

April

May

June

July

August

September

October

November

December

Total

Fill in all information applicable to your reporting area.

Please read instructions on back of sheet before completing, then E-mail completed forms to the address provided in the instructions (this data may also be sent via regular mail) see instructions for this address, also.

INSTRUCTIONS

1. For your reporting area, enter the number of actual event occurrences for each vital statistics area, by month of occurrence.

2. When this has been completed, total the numbers for each area and enter that on the line at the bottom of that column.

3. This is a count by occurrence, not by receipt or reporting, so use the actual month span (from the first day to the last day of the calendar month, the twenty-eighth, twenty-ninth, thirtieth, or thirty-first, as appropriate).

Marriages (or marriage licenses)

4. Include all marriages (or marriage licenses) reported to the state (or county, if applicable) office between the first and last day of each month.

Divorces and Annulments

5. Include only decrees of absolute divorce and annulments which are reported to the state office between the first and last day of each month. Exclude decrees of separation and other limited decrees.

6. Mail your report to:

MVSR Counts

Data Acquisition and Evaluation Branch, DVS

DHHS, PHS, CDC, NCHS

P.O. Box 12214; MS P09

3210 East Highway 54

Research Triangle Park, NC 27709

Telephone: 919-541-4550

Email: [email protected]

7. For additional forms or information on the reporting procedure, write to the above address or call the phone number above.

8. Your assistance in providing this information will make it possible for us to compile complete national data for publication in the Annual Vital Statistics Report. Legal authority for this information collection is provided under 42 USC 242k and the obligation to respond is voluntary

Example of Electronic Version of Form

Form Approved/OMB No. 0920-0213

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 30 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 data. An agency may not collect 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 Reports Clearance Officer: 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN.: PRA 0920-0213)

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL CENTER FOR HEALTH STATISTICS

DIVISION OF VITAL STATISTICS

RESEARCH TRIANGLE PARK, NC 27709

ANNUAL VITAL STATISTICS OCCURRENCE REPORT

______________________________

Registration Area (State or County, State)

MARRIAGE INSTRUCTIONS:

1. Report the number of marriages by month the marriage was performed.

2. If marriages by month performed are not available, please report marriages by month the license was filed in the state office and footnote accordingly.

3. Where data are not available, please enter three dashes (---). If the quantity is zero, use one dash (-).

4. If there are any other qualifications for the data, please indicate in a footnote.

2013 Marriages:

January		July
February		August
March		September
April		October
May		November
June		December
		Total

  

DIVORCE, DISSOLUTION OF MARRIAGE, AND ANNULMENT INSTRUCTIONS:

1. Report the total number of divorces, dissolution of marriages, and annulments granted by month of occurrence of decree.

2. Where data are not available, please enter three dashes (---) and if the quantity is zero, use one dash (-).

3. If there are any other qualifications for the data, please indicate in a footnote.

 

2013 Divorces, Dissolution of Marriages, and Annulments:

January		July
February		August
March		September
April		October
May		November
June		December
		Total

 

NOTE:

1. Please DO NOT provide monthly receipt counts in response to this request; as you know we receive "monthly counts" from your staff on an ongoing basis representing the number of certificates received in your office for the monthly report period.  The present request is not for "receipts" but rather for "occurrences".

2. Please DO NOT provide residence data; we need occurrence data only.