[NCHS] Application Form and Related Forms for the Operation of the National Death Index

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-26-0271 Data Use Agreement	Form and Instruction	New	Available
Form 0920-26-0271 Data Use Agreement	Form and Instruction	New	Available
Form 0920-26-0271 Data Destruction Form	Form and Instruction	New	Available
Form 0920-26-0271 NDI Early Release Fee Worksheet	Form and Instruction	Modified	Available
Form 0920-26-0271 NDI Fee Worksheet	Form and Instruction	Modified	Available
Form 0920-26-0271 National Death Index Early Release Transmittal Form	Form and Instruction	Modified	Available
Form 0920-26-0271 National Death Index Application Form	Form and Instruction	Modified	Available
Form 0920-26-0271 National Death Index Transmittal Form	Form and Instruction	Modified	Available
OMB0920-0215_Att I_IRB-ERB Letter_30d NDI Forms.pdf	Supplementary Document	Uploaded 2026-09-14	Available
OMB0920-0215_Att H_NDI Advisory Board Members v2.docx	Supplementary Document	Uploaded 2026-09-14	Available
OMB0920-0215_Att B2_Public Comment to the 60-Day Federal Register Notice and Program Response.docx	Public Comments	Uploaded 2026-09-14	Available
OMB0920-0215_Att A_Authorizing Legislation_30d NDI Forms.docx	Supplementary Document	Uploaded 2026-09-14	Available
Att G IRB.pdf	Supplementary Document	Uploaded 2023-02-08	Available
Att F National Death Index Advisors.docx	Supplementary Document	Uploaded 2023-02-08	Available
Att B Published 60-Day FRN.pdf	Supplementary Document	Uploaded 2023-02-08	Available
Att A Authorizing Legislation.docx	Supplementary Document	Uploaded 2023-02-08	Available
OMB0920-0215_Sup St B_30d NDI Forms v2_TM.docx	Supporting Statement B	Uploaded 2026-09-14	Available
OMB0920-0215_Sup St A_30d NDI Forms v2_TM.docx	Supporting Statement A	Uploaded 2026-09-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
282422	Supplemental NDI Data Use Agreement	Form and Instruction	New	Data Use Agreement
282421	NDI Data Use Agreement	Form and Instruction	New	Data Use Agreement
282420	Data Destruction Form	Form and Instruction	New	Data Destruction Form
239473	NDI - Early Release Fee Worksheet	Form and Instruction	Modified	NDI Early Release Fee Worksheet
239467	NDI - Fee Worksheet	Form and Instruction	Modified	NDI Fee Worksheet
239464	NDI Early Relase Transmittal Form	Form and Instruction	Modified	National Death Index Early Release Transmittal Form
239461	NDI - Application Form (electronic)	Form and Instruction	Modified	National Death Index Application Form
182824	NDI - Transmittal Form	Form and Instruction	Modified	National Death Index Transmittal Form

ICR Details

OMB Control No: 0920-0215	ICR Reference No: 202609-0920-003
Status: Received in OIRA	Previous ICR Reference No: 202301-0920-012
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-26-0271
Title: [NCHS] Application Form and Related Forms for the Operation of the National Death Index
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/14/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	3,026	0
Time Burden (Hours)	1,373	0
Cost Burden (Dollars)	0	0

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Abstract: The National Death Index (NDI) and the services it provides allows NCHS to collect mortality data to support epidemiological research and to furnish mortality information to approved public health and medical investigators. This is a Revision request for a three-year clearance to use of the administrative forms (the application form, repeat request form, and transmittal form) and the fee worksheets utilized in the operation of the National Death Index (NDI) program.

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Authorizing Statute(s): US Code: 42 USC 306 Name of Law: Public Health Service Act
  

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:
	91 FR 55594	08/28/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 58124	09/14/2026
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Data Destruction Form	0920-26-0271	Data Destruction Form
NDI - Application Form (electronic)	0920-26-0271	National Death Index Application Form
NDI - Early Release Fee Worksheet	0920-26-0271	NDI Early Release Fee Worksheet
NDI - Fee Worksheet	0920-26-0271	NDI Fee Worksheet
NDI - Transmittal Form	0920-26-0271	National Death Index Transmittal Form
NDI Data Use Agreement	0920-26-0271	Data Use Agreement
NDI Early Relase Transmittal Form	0920-26-0271	National Death Index Early Release Transmittal Form
Supplemental NDI Data Use Agreement	0920-26-0271	Data Use Agreement

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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	3,026	0	0	2,362	664	0
Annual Time Burden (Hours)	1,373	0	0	1,333	40	0
Annual Cost Burden (Dollars)	0	0	0	0	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 reinstatement of a previously approved collection for three years of approaval and 1374 annual burden hours.

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Annual Cost to Federal Government: $133,000

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: 09/14/2026

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