DeathCertificateReleaseAuthorizationForm-Child

OMB #: 0925-0593

OMB Expiration Date: 06/30/2017

N

ational Children’s Study

Authorization Form for Release of

Child Death Certificate

Full Name of Deceased Child

Sex of child: Male Female Date of Death or Stillbirth: /  / 

Month Day Year

Place of Death or Stillbirth- Hospital/Clinic (if applicable)

______________________________________ 

Place of Death or Stillbirth- City Place of Death or Stillbirth- State

______________________________________ ______________________________________

Name of Doctor (if applicable) Name of Funeral Director

Place of Burial

- - Not applicable

Social Security Number of Deceased

The measurement of children’s health is a primary research aim of the National Children’s Study (NCS). Information from the death certificate will only be used for statistical purposes in health research. We are asking you to authorize the state office of vital records to release the death certificate information of the child named above to researchers from the NCS.

Your child’s death certificate information will be used for research purposes only. All information will be kept private. Names and other identifying information will not be released without your permission.

 I PERMIT the NCS to obtain my child’s death certificate information.

 I DO NOT PERMIT the NCS to obtain my child’s death certificate information.

_________________________________________ _________________________________________________

Printed parent/guardian name (first, middle, last) Signature of parent/guardian

_________________________________________________

Relationship to Child

Date signed: // - -

m m d d y y y y Phone number

Questions related to the collection of death certificate information can be answered by NCS staff at 1-877-865-2619.

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.

Authorization Form for Release of Child Death Certificate, MDES 4.1, V1.0 1