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

Forms and Documents

Document Name	Status
Form 0920-0215 National Death Index - Application Form Form	Modified
Form 0920-0215 National Death Index - Transmittal Form Form	Modified
Form 0920-0215 National Death Index- Request for Repeat Application Form Form	Modified
Attachment G.pdf Supplementary Document	2010-09-23
Attachment F.pdf Supplementary Document	2010-09-23
Attachment E.pdf Supplementary Document	2010-09-23
Attachment A.pdf Supplementary Document	2010-09-23
1NDI Sup St A 2010-2012 091610.docx Supporting Statement A	2010-09-23

IC Document Collections

IC ID	Document Title	Status
6683	National Death Index - Application Form Form	Modified
182824	National Death Index - Transmittal Form Form	Modified
182823	National Death Index- Request for Repeat Application Form Form	Modified

ICR Details

OMB Control No: 0920-0215	ICR Reference No: 201010-0920-004
Status: Historical Active	Previous ICR Reference No: 200711-0920-012
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Application Form and Related Forms for the Operation of the National Death Index
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/02/2010
	Date Received in OIRA: 10/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2013	36 Months From Approved	12/31/2010
Responses	240	0	240
Time Burden (Hours)	182	0	182
Cost Burden (Dollars)	0	0	0

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Abstract: Researchers apply to use the National Death Index (NDI) to determine whether persons in their studies have died and to obtain information on the decedents' states, dates of death, death certificate numbers, and causes of death. The administrative forms are completed by researchers in order to apply for NDI services and to submit their study subjects' records for computer matching against the NDI file.

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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:
	75 FR 8364	02/24/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 58394	09/24/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
National Death Index - Application Form	0920-0215	National Death Index Application Form
National Death Index- Request for Repeat Application Form	0920-0215	Repeat Request for Application Form
National Death Index - Transmittal Form	0920-0215	Transmittal Form

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ICR Summary of Burden

	Total Approved	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	240	240	0	0	0	0
Annual Time Burden (Hours)	182	182	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $50,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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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: 10/12/2010

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