Monthly Vital Statistics Report

Attachment B

Example of the Paper Version

Form Approved/OMB No. 0920-0213{Private}

Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to average 10 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 data. An agency may not collect 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 Reports Clearance Officer: 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN.: PRA (0920-0213)

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL CENTER FOR HEALTH STATISTICS

DIVISION OF VITAL STATISTICS

RESEARCH TRIANGLE PARK, NC 27709

MONTHLY VITAL STATISTICS REPORT

Registration Area _______________________

(State or County, State)

Month and Year ex January 2014

The following were received for filing in this office:

_________ Birth certificates between _____________________ and _____________________.

(Month) (Day) (Month) (Day)

_________ Death certificates between _____________________ and ______________________.

(Month) (Day) (Month) (Day)

_________ Infant deaths were included in the count of death certificates above.

The following were reported to this office:

_________ Marriages between ________________________ and ________________________.

(Month) (Day) (Month) (Day)

_________ Divorces and annulments between __________________ and _________________.

(Month) (Day) (Month) (Day)

(Signed) _________________________________

(Official in charge)

Date ____________________________________

Please read instructions on back of sheet before completing, then E-mail or mail to address provided in instructions or in one of the pre-addressed envelopes provided by NCHS.

INSTRUCTIONS

(Monthly Vital Statistics Report)

Births/Deaths/Infant Deaths:

1. Report the number of certificates accepted for filing, received between two dates a month apart, without regard to date of occurrence. Note that this may mean:

a.Including more than one month=s shipment from a local office.

b.Including prior years events along with this years.

If certificates from a prior data year are received, please total them separately by event and year.

2.Use the same cutoff dates from month to monthC even though the cutoff date for births may be different from the cutoff date for deaths.

3.Include all certificates for deaths under one year of age in reporting the number of death certificates for infants.

4.Do not include fetal deaths (stillborns) in the counts of births and deaths.

Marriages (or marriage licenses)

5.Include all marriages (or marriage licenses) reported to the state (or county, if applicable) office between the two dates indicated on the front of this form. Include events reported between two dates a month apart, without regard to date of occurrence (or issuance). Use the same cutoff dates from month to month.

Divorces and Annulments

6.Include only decrees of absolute divorce and annulments which are reported to the state office between the two dates indicated on the front of this form. Exclude decrees of separation and other limited decrees. Include events reported between two dates a month apart, without regard to date of occurrence. Use the same cutoff dates from month to month.

For all monthly counts

7. Mail your report on or before the 25^th of the month following the month of report to:

MVSR Counts

Data Acquisition, Classification and Evaluation Branch, DVS

DHHS, CDC, OPHSS, NCHS

P.O. Box 12214; MS P09

3210 East Highway 54

Research Triangle Park, NC 27709

Telephone: 919-541-7642

Email: mvsr@cdc.gov

8. For additional forms or information on the reporting procedure, write or telephone to the above address.

9. Your assistance in providing this information will make it possible for us to compile complete national data for publication in the Monthly Vital Statistics Report. Legal authority for this information collection is provided under 42 USC 242k and the obligation to respond is voluntary.

Example of the Electronic Version

Form Approved/OMB No. 0920-0213{Private}

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 10 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 data. An agency may not collect 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 Reports Clearance Officer: 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0213)

Office of Management and Budget Number 0920-0213

Department of Health and Human Services

Centers for Disease Control and Prevention

National Center for Health Statistics

Division of Vital Statistics

P. O. Box 12214

Research Triangle Park, North Carolina 27709

MONTHLY VITAL STATISTICS REPORT

Please indicate on the form below, counts for births, deaths, infant deaths, marriages (or marriage licenses) and divorces and annulments, in the space provided by the underline. For birth and death counts, report the number of certificates received between two dates a month apart, without regard to date of occurrence. For infant death counts, include all certificates of death under one year of age. PLEASE do not include fetal deaths or stillbirths in the counts for births and deaths. For marriage counts (or marriage licenses), include all marriages reported to the state office between two dates a month apart, without regard to date of occurrence or issuance. For divorce and annulment counts, include only decrees of absolute divorce or annulments reported to the state office between two dates a month apart, without regard to date of occurrence. If possible, use the same time frame (or cutoff dates) from month to month, when providing counts for births, deaths, marriages, and divorces and Annulments. Your assistance in electronically providing this information will make it possible for us to compile complete national data for publication in MONTHLY VITAL STATISTICS REPORT. Legal authority for collecting this information is provided under 42 USC 242k, and the obligation to respond is voluntary.

We are requesting counts for the month of JANUARY 2014 and realize that some states have not provided MVSR counts for DECEMBER 2013. For these States, please provide counts electronically for JANUARY 2014 and DECEMBER 2013 as soon as you can. If you have any questions or concerns regarding electronic transmission of MVSR counts, please feel free to contact the Project Officer assigned to your state. If you have already submitted JANUARY 2014 counts, please disregard this message.

OUR email address is - mvsr@cdc.gov

____________________________________________________

Monthly Vital Statistics Report for the Month of JANUARY 2014:

STATE NAME: __________________

1) There were _____________ birth certificates received in this office between __________ and ___________.

month / day month / day

2) There were _____________ death certificates received in this office between __________ and ___________.

month / day month / day

3) There were ____________ infant deaths included in the count of death certificates.

4) There were _______ marriages reported to this office between __________ and ___________.

month / day month / day

5) There were _______ divorces and annulments reported to this office between __________ and ___________.

month / day month / day

6) TELEPHONE NUMBER and NAME of individual completing this form: ______________________________