ANNUAL POPULATION MORTALITY REPORTING FORM (ICD-9)
Form: E Version: 1 24.4.86
Seq.no:
Received:
MONICA Manual, Part II, Section 1
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Annual Demographic and Mortality data ANNUAL POPULATION MORTALITY REPORTING FORM (ICD-9) Form: E Version: 1 24.4.86 |
FOR MDC USE ONLY Seq.no: Received: |
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Please print carefully or type the requested information. Please complete all blanks in accordance with the instructions provided. Complete one form for each MONICA Reporting Unit for each sex each year.
| 1. | MONICA Collaborating Centre name: | Code:|___|___| |
| 2. | MONICA Reporting Unit name: | Code:|___|___| |
| 3. | Calendar year for which information is being provided: | |___|___|___|___| |
| 4. | The following table gives the official statistics for: | 1. Males, 2. Females Code |___| |
| Age group (years) |
Total deahts |
Total cardiovascular deaths 390-459 |
Number of deaths for selected ICD-9 categories | |||||
| 401-405 | 410-414 | 420-429 | 430-438 | 440-448 | Total | |||
| 25-29 | ||||||||
| 30-34 | ||||||||
| 35-39 | ||||||||
| 40-44 | ||||||||
| 45-49 | ||||||||
| 50-54 | ||||||||
| 55-59 | ||||||||
| 60-64 | ||||||||
| 65-69 | ||||||||
| 70-74 | ||||||||
| Total | ||||||||
| 5. | If you recorded the numbers in item 4 by hand, please write above each number printed to the right the numbers as used for item 4 | 0 1 2 3 4 5 6 7 8 9 | |
| 6. | Source of information: (enter correct code in box to the right) |
1. Local registry 2. Regional registry 3. National registry 4. Other (explain in item 8) |
Code:|___| |
| 7. | Person providing information: | ___________________ (Please type or print) |
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| Signature: | ___________________ | Date: _____/_____/_____ day month year |
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| 8. | Comments or reservations about data provided:
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Note for the HTML-version: These instructions were extracted word to word from Version 1 of Form E, which was part of the December 1986 revision of the MONICA Manual. Therefore, references to other sections of the Manual also refer the December 1986 revision, which has not been converted to HTML.
The purpose of this form is to provide a convenient and common format for reporting annually the official statistics of the total number of deaths and the number of cardiovascular disease deaths among residents of each official MONICA Reporting Unit. The numbers provided on this form are an essential component in the investigation of cardiovascular disease mortality trends.
This form is to be completed once each year and reported to the MONICA Data Centre (MDC), so that it is received there by 31 December each year. The information should be provided for the calendar year immediately preceding the year of reporting the data. For example, the data for 1984 should be reported by 31 December 1985. Please inform the MDC and the MONICA Management Centre (MMC) if there is any difficulty in meeting this schedule.
In addition to the yearly reporting, the information should be reported whenever requested by the MMC. Such additional requests may concern the very early years of event registration.
The time period for which information is to be reported is the calendar year (1 January through 31 December) as stated on the form. The data provided are to be the best available estimates of the number of deaths occurring among MONICA Reporting Unit residents during this calendar year.
The information is to be provided separately for males and females for deaths of residents of each MONICA Reporting Unit. See Appendix 2 for a list of these Reporting Units and code numbers.
This form is to be used for those death registration systems using the International Classification of Diseases 1975 Revision (ICD-9). If the source of information for the numbers of deaths reported here uses ICD-9 codes, then this form should be used. If the source uses the International Classification of Diseases 1965 Revision (ICD-8) then the ICD-8 form should be used. If neither of these systems of coding causes of death are used, please contact the MDC for instructions.
This form is to be completed by the MCC Principal Investigator or by someone officially designated to perform this task.
This form can be completed either by typewriter or by hand. In either case the recorded information should be examined carefully for both correctness and legibility. Further, since it may be necessary to photocopy the form, perhaps several times, as a routine part of processing and providing reserve copies it is essential that the recorded information be clear and dark. Hence, please use a dark ribbon if a typewriter is used or a dark ball-point pen if the form is completed by hand.
This form includes blank spaces where you are to record the requested information. None of these spaces should be left blank. If you have no information to provide for a specific item, then so indicate according to the instructions for that item.
The instructions for each item also indicate how to correct a misrecorded entry. Please follow these instructions carefully; if the number of corrections required has made the form difficult to read or perhapse confusing, please re-enter the information on a new copy and send this new copy of the form to the MDC. If this step is required, please check the final copy carefully to make sure that no new errors were made in the process of re-copying the numbers onto the new form.
These instructions should be followed carefully when completing the indicated version of the Annual Population Mortality Reporting Form (ICD-9). Please ensure that the instructions are for the version of the form being completed. Specific instructions are listed by item below:
| 1. | MONICA Collaborating Centre name: | Code:|___|___| |
Print or type the official MONICA Collaborating Centre name and code number in the spaces provided. Use the name and code number as they appear in Appendix 2: Official MONICA Collaborating Centre and Reporting Unit Names and Code Numbers. If your centre is not listed or is erroneously listed in this appendix, contact the MDC for instructions.
Example:
Correcting mistakes: If a mistake is made in entering information for this item, please draw a single line through the erroneous entry and provide the correct information immediately to the right. Even if only one digit of the code number is incorrect, please draw a line through the entire number and re-write the correct number immediately to the right as is indicated below.
| 2. | MONICA Reporting Unit name: | Code:|___|___| |
Print or type the official MONICA Reporting Unit name and code number in the space provided. Use the name and code number as they appear in Appendix 2. Even if your centre has only one Reporting Unit, please enter the appropriate name and code number here. Do not leave this item blank. If your centre has more than one Reporting Unit, then complete one form for each of them and record the appropriate name and code number for each Reporting Unit in this space.
Correcting mistakes: Use the same procedure as indicated for Item 1 above.
| 3. | Calendar year for which information is being provided: | |___|___|___|___| |
Print or type the calendar year (1 January through 31 December) for which data are being provided. Please contact the MDC for instructions and note in item 8 if the reporting period does not correspond to a calendar year as described above. Include all four digits of the year as described in the sample below.
Example (with error correction):
| 4. | The following table gives the official statistics for: | 1. Males, 2. Females Code |___| |
Note that separate forms are to be completed for males and females. For each form print or type the appropriate number in the coding box to the right.
Example (with error correction):
Print or type the official number of deaths among residents of the official MONICA Reporting Unit for each age group - ICD-9 code combination in the appropriate cell.
Note: If you have decided to exclude some people living in the Reporting Unit area (e.g. those who are not citizens of the country) from the survey sample and event monitoring, such population groups are excluded from the MONICA study population. Hence, such people must not be counted here.
Correcting mistakes: If a mistake is made in entering information for this item, please draw a single line through the erroneous entry and write and circle a capital letter in the cell of the erroneous entry. In the right side of the table, print or type and circle the same letter followed by the correct number. Use different letters for different corrections.
An example of a table with a properly completed error correction follows. This example is for a MONICA Reporting Unit which includes ages 65-69 and 70-74. The second example indicates how to fill in the table for those reporting units for which only the core ages 25-64 are being included in the surveillance activities.
Example when only ages 25-64 are included:
In this example, the totals are for all ages 25-64. If age 65-69 is included but 70-74 is not, then NA would appear only for ages 70-74. Otherwise, the procedure for completing the table is the same as above.
After the values are recorded, they should be checked against the information source and all totals recalculated. If any errors are discovered, then the correction should be made as described above.
| 5. | If you recorded the numbers in item 4 by hand, please write above each number printed to the right the numbers as used for item 4 | 0 1 2 3 4 5 6 7 8 9 |
This item was added as an attempt to help read hand-written entries that may appear elsewhere on this form. If you are entering data on this form by typewriter, leave this item blank. If you are completing the form by hand, please write, in your handwriting, each number above the digits as shown in the example below. Then compare the entries in the table and elsewhere on the form with those as written for this item and change those that may be confusing or unclear.
Example:
| 6. | Source of information: (enter correct code in |
1. Local registry 2. Regional registry 3. National registry 4. Other (explain in item 8) |
Code:|___| |
Print or type the appropriate number in the box for the code number. If the source of the information is not the same as reported for the previous year, please indicate the reason for the change in item 8.
Use codes as follows:
| 1 | Local registry: use this code if the numbers of deaths by cause were obtained directly from a local registration system with the area covered by this system corresponding exactly with the area of the MONICA Reporting Unit. |
| 2 | Regional registry: use this code if the numbers of deaths by cause were obtained directly from a regional registration system which covers a broader area than the MONICA Reporting Unit area, but which does not cover the entire country. Clearly, if such a registry is used, the deaths occurring among residents of the MONICA Reporting Unit must be identifiable as having occurred in that Reporting Unit. |
| 3 | National registry: use this code if the numbers of deaths by cause were obtained from a national registration system. |
| 4 | Other: use this code if none of the other codes are applicable. Please describe clearly in item 8 the source of information if "other" is coded. |
Example (with error correction):
| 7. | Person providing information: | ___________________ (Please type or print) |
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| Signature: | ___________________ | Date: _____/_____/_____ day month year |
Type or print the name of the person completing this form and the date completed in the spaces provided. Note that this form is to be completed by the Principal Investigator of the MCC or his or her designate.
| 8. | Comments or reservations about data provided: |
Type or print any reservations or comments about the data that may be helpful to the MDC in using the data or preparing summary reports. Note especially the instructions for items 3 and 6. If necessary, attach additional sheets.