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Form 120 - Initial Notification of Death
Ver. 8.1
OMB #0925-0414 Exp: 07/13
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. 8.1
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
File Type | application/pdf |
File Title | COMMENTS |
Author | Women's Health Initiative |
File Modified | 2013-01-15 |
File Created | 2013-01-15 |