Disaster-Related Mortality Surveillance Form
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1Disaster-related Mortality Surveillance Form .Complete one form per decedent
Complete the form for all known deaths related to a disaster: This information should be obtained from a medical examiner, coroner,
decedent
hospital, funeral home or DMORT (Disaster Mortuary Team) office. Please, complete one form per
.
Form v1.1
Rev.03/21/2007
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
21. Body recovered by:
worker 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
Motor Vehicle occupant/driver
Stroke (hemorrhagic or thrombotic)
disaster:
Pedestrian/bicyclist struck by vehicle
Other (specify)_______________
Direct
Possible
Structural collapse
Respiratory failure
Indirect
Undetermined
Fall
COPD
26. Circumstance of death: (free text)
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
Extreme heat (e.g., hyperthermia)
GI and endocrine
27. Manner/intent of death:
Extreme cold (e.g., hypothermia)
Bleeding
Natural
Suicide
Other (specify)________________
Hepatic failure
Accident
Pending
Unknown cause of injury
Pancreatitis
Homicide
Undetermined
Diabetes complication
28. Who signed the death certificate?
Sepsis
ME/coroner
Dehydration
Physician
Allergic reaction
Not signed
Other (specify)___________________
29. Date of report completed:
Unknown cause of illness
(MM/DD/YY) ___/____/______
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