Disaster-related Mortality Surveillance Form .Complete one form per
decedent

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

Disaster-related Mortality Surveillance. General Instruction for
completion of mortality form