Part I - Centers for Disease Control and Prevention
Disaster-related Mortality Surveillance Form .Complete one form per decedent
|Part I General information |
|1.Type of disaster: |2. Facility type (info source): Please check one that best applies. |
|( Hurricane (name_________) ( Heat wave |( ME office ( Funeral home ( Nursing home |
|( Tornado ( Technological disaster |( Coroner office ( Hospital |
|( Flood ( Terrorism |( DMORT office ( Other (specify)___________________ |
|( Earthquake ( Other (specify)________ | |
|3. Facility address: |4. Contact person (informant): |
|Street ______________________ County/parish_____________ |Name________________________ Phone number______________ |
|State_______________________ Z-code_________ |Email Address_______________________ |
|Part II Deceased information |
|5. Case / medical record number: _______________ |6. Body identified? ( Yes ( No ( Pending |
|7. Date of Birth (MM/DD/YY) ___ /___/____ ( Unknown |8. Age in years:_____( < 1 yr ( Unknown |
|9. Residential address of decedent: |10. Ethnicity: |11. Race: |
|County/parish__________ City____________ |( Hispanic |( American Indian or Alaskan Native ( White |
|State_________ Zip code___ |( Non Hispanic |( Black or African American ( Asian |
| |( Unknown |( Native Hawaiian or other Pacific Islander ( Other race |
|12. Gender: |13. Date of Death: |14. Time of Death: | 15. Date of body recovery: |
|( Male ( Female |(MM/DD/YY) ____ /____/_____ |( ______(24 hr clock) |(MM/DD/YY) |
|( Undetermined |( Unknown |( Unknown |____/____/______ ( Unknown |
|16. Time of body recovery: | 17. Place of death or body recovery: |
|( ________ (24 hr clock) |( Decedent’s home ( Evacuation Center/shelter ( Vehicle ( Hospital |
|( Unknown |( Hotel /motel ( Nursing Home / long term care facility ( Hospice facility ( Unknown |
| |( Street/Road ( Prison or detention center ( Other (specify)______________ |
|18. Location of death or body recovery: |19. Prior to death, the individual was a: |
|State_____ county/parish___________ |( Resident ( Non-resident-intrastate ( Unknown |
|Intersection______________________ |( Foreign ( Non-resident-interstate ( Other________ |
|20. Was the individual paid or volunteer worker |21. Body recovered by: |
|involved in disaster response? |( Law enforcement ( Fire department ( DMORT ( Other (specify)______ |
|( Yes ( No (Unknown |( EMS ( Search and rescue ( Family or individual ( Unknown |
|Part III Cause and Circumstance of death (check one that best applies) |
|22. Mechanism or cause of death— Injury |23. Cause of death— Illness |24. Cause of death: |
|( Drowning |( Neurological disorders |( Confirmed ( Probable |
|( Electrocution |( Meningitis/encephalitis |( Pending ( Unknown |
|( Lightning |( Seizure disorder |25. Relationship of cause of death to disaster: |
|( Motor Vehicle occupant/driver |( Stroke (hemorrhagic or thrombotic) |( Direct ( Possible |
|( Pedestrian/bicyclist struck by vehicle |( Other (specify)_______________ |( Indirect ( Undetermined |
|( Structural collapse |( Respiratory failure |26. Circumstance of death: (free text) |
|( Fall |( COPD | |
|( Cut/struck by object/tool |( Pneumonia | |
|( Poisoning/ toxic exposure: |( Asthma | |
|( CO exposure |( Pulmonary embolism | |
|( Inhalation of other fumes/smoke, dust, gases |( Other (specify)________________ | |
|( Ingestion of drug or substance |( Cardiovascular failure | |
|( Other (specify)___________________ |( ASCVD | |
|( Suffocation/asphyxia |( Congestive heart failure | |
|( Burns (flame or chemical) |( Other (specify)________________ | |
|( Firearm/gunshot |( Renal failure |27. Manner/intent of death: |
|( Extreme heat (e.g., hyperthermia) |( GI and endocrine |( Natural ( Suicide |
|( Extreme cold (e.g., hypothermia) |( Bleeding |( Accident ( Pending |
|( Other (specify)________________ |( Hepatic failure |( Homicide ( Undetermined |
|( Unknown cause of injury |( Pancreatitis |28. Who signed the death certificate? |
| |( Diabetes complication |( ME/coroner |
| |( Sepsis |( Physician |
| |( Dehydration |( Not signed |
| |( Allergic reaction |29. Date of report completed: |
| |( Other (specify)___________________ |(MM/DD/YY) ___/____/______ |
| |( Unknown cause of illness | |
Complete the form for all known deaths related to a disaster: This information should be obtained from a medical examiner, coroner, hospital, funeral home or DMORT (Disaster Mortuary Team) office. Please, complete one form per decedent.
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Form v1.1 Rev.03/21/2007
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