NDI - Application Form (electronic)

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⚠️ Notice: This information collection may be referencing outdated material.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
NDI - Application Form (electronic) Form and Instruction
National Death Index Application Form Att C2 Application Form Electronic 121319.docx Form and Instruction

Information Collection (IC) Details

IC Title:	NDI - Application Form (electronic)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	n/a	National Death Index Application Form	Att C2 Application Form Electronic 121319.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: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	120	110	10
Annual IC Time Burden (Hours)	300	270	30
Annual IC Cost Burden (Dollars)	12,366	11,129	1,237

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.