National Death Index Transmittal Form

Name of Principal Investigator/Project Director:	Phone number:	Assigned NDI application (search) number:
Organization:

Recipient of express-mailed NDI results:	Person to contact if NCHS has
(Include street address and room number, not just P.O. Box)	problems processing your records:
	Name of Person:
	Phone number:
	E-mail:
Phone number: E-mail:

1. What year(s) of death do you want to search? If you are submitting MORE THAN ONE FILE (SEE ITEM 7 FOR REFERENCE), submit a separate NDI Transmittal Form for each file. Contact NDI staff if you are not sure which years are currently available.)	Beginning year Ending year
2. Is this a REVISED data submission to correct errors from a previous submission?		YES	NO
3. Date sent to NCHS:	4. Records (100 characters) submitted on: CD–ROM sFTP
5 . TOTAL number of (100-character) records: Number of study subjects* *Charges are based only on number of subjects ____________________ Duplicate/alias records (optional) 0

Notice: CDC will keep the information you provide on the NDI application and forms private and secure to the extent permitted by law.

CDC estimates the average public reporting burden for this collection of information as 18 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D–74, Atlanta, GA 33033, ATTN: PRA (0929–0215).

Form Approved

OMB No. 0920-0215

E xp. Date xx/xx/20xx

(CONTINUE ON BACK OF PAGE)

7a. File type: Routine	Unknown	Known	Certificate	7b. Did your original application form only request routine searches?			Yes	No
8. Special instructions: (Use this box if there is anything you need to tell us about how your records were prepared. NOTE: If your data submission contains more than one file type, complete a separate NDI TRANSMITTAL FORM for each file type, clearly indicating which YEAR(S) OF DEATH each file type should be searched against.)
9. Payment is being made by:				EIN 58–605–1157	10. Amount of payment: (Confirm with NDI staff if necessary) Service charge Total record charges (duplicate records at no charge) TOTAL PAYMENT $ 0.00
Check attached pending Credit card (limit $100,000.00) Purchase order: # Interagency agreement (specify): Other (specify):
Person authorized to request this NDI search (print):			Signature: Only federal employees may sign digitally			Date

FOR NCHS OFFICE USE ONLY

Date data recieved: Date searched: Date NDI output sent:	Total records:	NDI CHARGES: Service charges Total record charges $ 0.00 T OTAL PAYMENT
Rejected records:
Type of output: CD/ROM sFTP Programmer’s initials:

Required action:

Deposit check Invoice against purchase order Charge interagency agreement #

Special instructions or comments: