Form 4 Initial Notification of Death

OMB Control Number: 0925-0414
Expiration Date: 7/2016
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 (0925-0414). Do not
return the completed form to this address.

WHI

Form 120 - Initial Notification of Death

Ver. 8.2
OMB #0925-0414 Exp: 07/16

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 OMV 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
Office, 6705 Rockledge Drive, MSC 7730, Bethesda, MD 20892-7730, ATTN: PRA
(0925-0414). Do not return the completed form to this address.

Contact date:

-

Completed by:

-

Contact type:

1

2

1. What is the date of death?

Member ID: __ __

__ __ - ___ ___ ___ - __

First Name _______________________M.I.______
Last Name ________________________________

(M/D/Y)

-

Phone

-Affix label here-

Mail

-

8

Other
(M/D/Y)

-

2. Source of notification: (Mark one.)

1
2
3

Family member
Friend/associate of deceased

4 NDI
8Other

(CCC use only)
____________________________________

Personal physician
2.1. Name, address and phone number of the source.
Name:

___________________________________________________
Provider ID

Address: ___________________________________________________
___________________________________________________
Phone Number: (____) ________________________________________

3. Did the death occur in a hospital/medical institution (i.e., hospital, long term care facility, hospice)?

0

1 Yes

No

9 Unknown

Go to Page 2.

3.1. Name, address and phone number of the hospital/medical institution
(i.e., hospital, long term care facility, hospice).
Hospital Name: ______________________________________________
City/State:

Provider ID

______________________________________________

Phone Number: (____) ________________________________________
Go to Page 2.
3.2.

Location and address of death, if death did not occur in a hospital/medical institution.
Location:

________________________________________________________________

Address:

________________________________________________________________
_________________________________________________________________
RV_________K___________V___________

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WHI

Form 120 - Initial Notification of Death

Ver. 8.2

4. Was an autopsy done?

0 No
9 Unknown

1 Yes

4.1. Name, address and phone number where autopsy was performed.
Name:

___________________________________________________

Address: ___________________________________________________

Provider ID

___________________________________________________
Phone Number: (____) ________________________________________
5. Where will the death certificate be obtained?

1
2
3
8
9

Coroner/Medical Examiner
Personal physician
Vital Statistics Office
Other (Specify): _________________________
Unknown
5.1. Name, address and phone number of individual providing the death certificate.
Provider ID

Name:

___________________________________________________

Address: ___________________________________________________
___________________________________________________
Phone Number: (____) ________________________________________
6. (Ask of source): To the best of your knowledge, what was the underlying cause of death?

____________________________________________________________________________
____________________________________________________________________________
7. On the basis of currently available data, what was the underlying cause of death? (Mark one.)
Cancer

1 Breast
2 Ovarian
3 Endometrial
4 Colon
5 Rectosigmoid junction
6 Rectum
7 Uterus
10 Lung
8 Other cancer
________________

9 Unknown cancer site

Cardiovascular Disease

11 Coronary Heart Disease (CHD)
12 Cerebrovascular disease
13 Pulmonary Embolism
18 Other cardiovascular disease
19 Unknown cardiovascular disease
Accident/Injury

21 Homicide
22 Accident
23 Suicide
28 Other Injury ___________________

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Pg. 2 of 2

“Other” Cause of Death

31 Alzheimer’s Disease
32 COPD
33 Pneumonia
34 Pulmonary Fibrosis
35 Renal Failure
36 Sepsis
88 Another cause of death, known
______________________

99 Unknown cause of death