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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