NDI Transmittal Form

Express mail THIS FORM and your FILE to:

NATIONAL DEATH INDEX

Division of Vital Statistics

National Center for Health Statistics 3311 Toledo Road, 7318

Hyattsville, MD 20782

Phone 301–458–4444

Be sure to enclose:

1. Study subjects’ records (sFTP or CD-ROM)

2. Completed NDI Transmittal Form

3. Worksheet for calculating NDI charges

4. Payment (check, purchase order, or credit card)*

*Make check payable to the U.S. Dept. of Health and Human Services

and include both your NDI and EIN numbers.

NOTE: Our Employer Identification Number (EIN) is 58–605–1157.

Name of Principal Investigator/Project Director:	Phone number:	Assigned NDI application (search) number:
Organization:

1. What year(s) of death do you want to search? If you are submitting MORE THAN ONE FILE, submit a separate NDI Transmittal Form for each file. Contact NDI staff if you are not sure which years are currently available.)	Beginning year Ending year
2. Is this a REVISED data submission to correct errors from a previous submission?	YES NO
3. Date sent to NCHS:	4. Records (100 characters) submitted on: CD–ROM sFTP
5. TOTAL number of (100-character) records: How many of these are duplicate/alias records (optional)

(CONTINUE ON BACK OF PAGE)

7. File type: Routine	Unknown	Known		Certificate
8. Special instructions: (Use this box if there is anything you need to tell us about how your records were prepared. NOTE: If your data submission contains more than one file type, complete a separate NDI TRANSMITTAL FORM for each file type, clearly indicating which YEAR(S) OF DEATH each file type should be searched against.)
9. Payment is being made by:				EIN 58–605–1157	10. Amount of payment: (Confirm with NDI staff if necessary) Service charge Total record charges (duplicate records at no charge) TOTAL PAYMENT
Check attached pending Credit card (limit $100,000.00) Purchase order: # Interagency agreement (specify): Other (specify):
Person authorized to request this NDI search (print):			Signature:			Date

Date data recieved: Date searched: Date NDI output sent:	Total records:	NDI CHARGES: Service charges Total record charges TOTAL PAYMENT
	Rejected records:
Type of output: CD/ROM sFTP Programmer’s initials:

FOR NCHS OFFICE USE ONLY

Required action:

Deposit check Invoice against purchase order Charge interagency agreement #

Special instructions or comments:

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m). In addition, NCHS complies with the Cybersecurity Enhancement Act of 2015. This law requires the Federal government to protect its information by using computer security programs to identify cybersecurity risks against federal computer networks.

Public reporting burden of this collection of information is estimated to average 18 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 Reports Clearance Officer; 1600 Cliffton Road, MS D–74, Atlanta, GA 33033, ATTN: PRA (0929–0215, Exp. Date xx/xx/20xx).