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
National Death Index Application Form	Form and Instruction	Modified	Available
NDI Early Release Fee Worksheet	Form and Instruction	New	Available
NDI Fee Worksheet	Form and Instruction	New	Available
National Death Index Early Release Transmittal Form	Form and Instruction	New	Available
National Death Index Application Form	Form and Instruction	New	Repair queued
National Death Index Transmittal Form	Form and Instruction	Modified	Available
National Death Index Repeat Request Form	Form and Instruction	Modified	Available
Att H NDI Advisory Board Members.docx	Supplementary Document	Uploaded 2020-01-24	Available
Att G IRB.pdf	Supplementary Document	Uploaded 2020-01-24	Available
Att B1 60-day FRN.pdf	Supplementary Document	Uploaded 2020-01-24	Available
Att A Authorizing Legislation.docx	Supplementary Document	Uploaded 2020-01-24	Available
NDI Sup St B_01152020.docx	Supporting Statement B	Uploaded 2020-01-24	Available
NDI Sup St A_01152020.docx	Supporting Statement A	Uploaded 2020-01-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6683	NDI - Application Form (paper)	Form and Instruction	Modified	National Death Index Application Form
239473	NDI - Early Release Fee Worksheet	Form and Instruction	New	NDI Early Release Fee Worksheet
239467	NDI - Fee Worksheet	Form and Instruction	New	NDI Fee Worksheet
239464	NDI Early Relase Transmittal Form	Form and Instruction	New	National Death Index Early Release Transmittal Form
239461	NDI - Application Form (electronic)	Form and Instruction	New	National Death Index Application Form
182824	NDI - Transmittal Form	Form and Instruction	Modified	National Death Index Transmittal Form
182823	NDI - Repeat Request Form	Form and Instruction	Modified	National Death Index Repeat Request Form

ICR Details

OMB Control No: 0920-0215	ICR Reference No: 201912-0920-014
Status: Historical Active	Previous ICR Reference No: 201903-0920-004
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: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/06/2020
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved
Responses	1,730	0	0
Time Burden (Hours)	787	0	0
Cost Burden (Dollars)	32,460	0	0

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Abstract: This is a reinstatement with change request for a three-year clearance to use of the administrative forms (the application form, repeat request form, and transmittal form) and the fee worksheets utilized in the operation of the National Death Index (NDI) program.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 54147	10/09/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 5663	01/31/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
NDI - Application Form (electronic)	n/a	National Death Index Application Form
NDI - Application Form (paper)	n/a	National Death Index Application Form
NDI - Early Release Fee Worksheet	n/a	NDI Early Release Fee Worksheet
NDI - Fee Worksheet	n/a	NDI Fee Worksheet
NDI - Repeat Request Form	n/a	National Death Index Repeat Request Form
NDI - Transmittal Form	n/a	National Death Index Transmittal Form
NDI Early Relase Transmittal Form	n/a	National Death Index Early Release Transmittal Form

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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	1,730	0	0	1,430	10	290
Annual Time Burden (Hours)	787	0	0	300	30	457
Annual Cost Burden (Dollars)	32,460	0	0	31,223	1,237	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Using Information Technology

Short Statement: The paper version of the Application Form is still available as an option, but fewer respondents are expected to use the form (3 hours per response). A more efficient electronic version of the Application Form is available at decreased burden per response (2.5 hours per response). Overall ICR burden will increase due to anticipated increases in the number of Application forms, Repeat Request forms, and Transmittal forms, and inclusion of the Fee Worksheet and the Early Release Fee Worksheet.

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Annual Cost to Federal Government: $133,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

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Common Form ICR:  No

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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: 01/31/2020

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