NDI - Application Form (paper)

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⚠️ Notice: This information collection may be referencing outdated material.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 (paper) Form and Instruction
National Death Index Application Form Att C1 Application Form Paper_121219.docx Form and Instruction

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

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 C1 Application Form Paper_121219.docx		No		Paper Only

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: 10	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 Potential Violation of the PRA
Annual Number of Responses for this IC	10	-90	100
Annual IC Time Burden (Hours)	30	-370	400
Annual IC Cost Burden (Dollars)	1,237	1,237	0

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.