National Death Index Application Form
Application Form and Related Forms for the Operation of the National Death Index
Att C2 Application Form Electronic 121319
NDI - Application Form (electronic)
OMB: 0920-0215
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0215 can be found here:
Document [docx]
Download: docx | pdf
Notice: CDC will keep the
information you provide on the NDI application and forms private and
secure to the extent permitted by law.
XX/XX/20XX
Page 2 – part 1 (Top) – all 1 screen
Page 2 – part 2 (Bottom) – all 1 screen
Page 5 – part 1 (Top)
Page 5 – part 2 (bottom section – all 1 screen)
Page 6 – part 1 (Top) – This is expanded view – 10c = Yes. If No, the box vanished below 10c
Page 6 – part 2 (bottom – expanded view) – I put “UNKNOWN” in item 1 for date – so it expands by requiring a justification.
This page required at least two PDF attachments – but users can upload up to 99 attachments.
When IDENTIFYING or IDENTIFIABLE death record information is clicked, the following pops up:
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Hildreth, Alston C. (CDC/DDPHSS/NCHS/DVS) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |
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