National Death Index Early Release Transmittal Form

Early Release
Transmittal Form
OMB No. 0920-0215
Expiration Date: xx/xx/2026

If sending your submission via mail, please use this address:

You must enclose:
1.

Study subjects’ records (sFTP or CD-ROM)

2.

Completed NDI Transmittal Form

3.

Worksheet for calculating NDI charges

4.

NATIONAL DEATH INDEX
Division of Vital Statistics
National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782
Phone: 301–458–4444

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:

Organization:

Assigned NDI application number:

Name of site principal investigator/project director:

Site Indicator:

Person to contact if NCHS has problems
processing your records:

Data steward name:
Organization’s physical address (P.O. Boxes are not permitted):

Name:

E-mail:
Phone Number:

E-mail:

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:
YES

2. Is this a REVISED data submission to correct errors from a previous submission?
3. Date sent to NCHS:

4. Records (100 characters) submitted on:

CD–ROM

5. TOTAL number of (100-character) records:

sFTP

Number of study subjects*:
*Charges are based only on number of subjects
Duplicate/alias records (optional):

6. Preferred output medium:
Your NDI results are sent on a
CD–ROM unless a different medium
is indicated.

CD–ROM
sFTP

(CONTINUE ON BACK OF PAGE)

NO

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, complete a separate NDI TRANSMITTAL FORM for each file, clearly indicating which YEAR(S) OF DEATH each
file should be searched against.)

EIN 58–605–1157

9. Payment is being made by:
Check

Attached

Pending

10. Amount of payment:
(only one service charge per submission, not per form)
Service charge:

Credit card (limit $24,999.99)
Purchase order: #

Total record charges:
(5 duplicate records per subject at no charge)

Interagency agreement (specify):
Electronic Funds Transfer

Total payment:

Other (specify):
Signature:

Person authorized to request
this NDI search (print):

Date:

FOR NCHS OFFICE USE ONLY
Total records:

Date data recieved:

Rejected records:

Date searched:
Date NDI output sent:

Type of output:

NDI CHARGES:
Service charges:

Total record charges:
CD/ROM

sFTP
Total payment:

Programmer’s initials:

Required action:

Deposit check

Invoice against purchase order

Charge interagency agreement number:

If charge was selected, include interagency agreement number:
Special instructions or comments:

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).

CS329646
03/2022