National Death Index Early Release Transmittal Form

Early Release

Transmittal Form

Express mail THIS FORM and your FILE to:

NATIONAL DEATH INDEX

Division of Vital Statistics

National Center for Health Statistics 3311 Toledo Road, 7318

Hyattsville, MD 20782

Phone 301–458–4444

Be sure to enclose:

1. Study subjects’ records (sFTP or CD-ROM)

2. Completed NDI Transmittal Form

3. Worksheet for calculating NDI charges

4. Payment (check, purchase order, or credit card)*

*Make check payable to the U.S. Dept. of Health and Human Services and include both your NDI and EIN numbers.

NOTE: Our Employer Identification Number (EIN) is 58–605–1157.

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

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

1. What year(s) of death do you want to search? If you are submitting MORE THAN ONE FILE, submit Beginning year a separate NDI Transmittal Form for each file. Contact NDI staff if you are not sure which years are currently available. Ending year available.)
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)

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 2 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).

(CONTINUE ON BACK OF PAGE)

Form Approved

OMB No. 0920-0215

Exp. Date: xx/xx/20xx

7. File type: Routine Unknown Known Certificate
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, complete a separate NDI TRANSMITTAL FORM for each file, clearly indicating which YEAR(S) OF DEATH each file 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
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:

Date

FOR NCHS OFFICE USE ONLY
Date data received: ________________ Date searched: ____________________ Date NDI output sent:	Total records:			NDI CHARGES: Service charges ______________________ Total record charges ______________________ TOTAL 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: