Certificate of Death Supplemental Information Worksheet

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0720-COFD_AFMETS PIA_9.25.2024.pdf	Supplementary Document	Uploaded 2024-10-17	Repair queued
DD2064 DRAFT 20240730.pdf	Supplementary Document	Uploaded 2024-10-15	Missing upstream
0720-COFD_DD2064_SSN MEMO_8.7.2019.PDF	Supplementary Document	Uploaded 2024-10-15	Repair queued
0720-COFD_SSA_10.15.2024.docx	Supporting Statement A	Uploaded 2024-10-15	Repair queued
Screen Shot of AFMETs information populated by DCIPS for completion of DD2064.docx	Supplementary Document	Uploaded 2024-01-18	Repair queued
DC Info Request Script - V3.b. - Calling Family Member.docx	Supplementary Document	Uploaded 2024-01-18	Repair queued
DC Info Request Script - V3.a. - Script to Call Partners.docx	Supplementary Document	Uploaded 2024-01-18	Repair queued
Race Form Field Justification (v9-30-2024).pdf	Supplementary Document	Uploaded 2024-10-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
264012	Certificate of Death and Information Worksheet	Other-Fillable PDF	New

ICR Details

OMB Control No:	ICR Reference No: 202308-0720-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-COFD
Title: Certificate of Death Supplemental Information Worksheet
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/18/2024

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	50	0
Time Burden (Hours)	50	0
Cost Burden (Dollars)	363	0

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Abstract: Department of Defense (DoD) Form 2064, “Certificate of Death,” is used by family members of deceased DoD employees and contractors to settle estates, insurance claims, and other post death related matters. This form is also used by the DoD to track the cause and manner of death of service members, federal employees, their family members and dependents when a death occurs outside the continental United States (OCONUS). DD Form 2064 generates a death certificate that is accessible to next-of-kin. The form is also used by OCONUS hospitals and allows for the transportation of human remains.

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Authorizing Statute(s): US Code: 10 USC 1471 Name of Law: Forensic Pathology Investigations
   US Code: 10 USC 1509 Name of Law: Program to Resolve Missing Persons Cases
  

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:
	88 FR 72442	10/20/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 82583	10/11/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certificate of Death and Information Worksheet

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	50	0	0	50	0	0
Annual Time Burden (Hours)	50	0	0	50	0	0
Annual Cost Burden (Dollars)	363	0	0	363	0	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: No

Burden Reduction Due to:

Short Statement: This is a new collection associated with new burden.

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Annual Cost to Federal Government: $3,031

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? No

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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: 10/18/2024

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