FORM NO.

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(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in-patients. Not to be used for still births)
To be sent to Registrar along with Form No. 2 (Death Report)

Name of the Hospital ……………………………................……………..

I hereby certify that the person whose particulars are given below died in the hospital
in Ward No. ………. On at ………. AM/PM.
NAME OF DECEASED
Sex Age at Death For use
If 1 year or If less than 1 If less than If less than one of
more, year, one month, day, age in Statistical
age in years age in months age in Days Hours Office
1. Male
2. Female
CAUSE OF DEATH Interval
between on set
& death approx.
I. (a)……………………………………
Immediate cause …………….
State the disease, injury or complication which Due to (or as a consequences of)
caused death, not the mode of dying such as
heart failure, asthenia etc.
Antecedent cause (b)……………………………………
Morbid conditions, if any, giving rise to the …………………..
above Cause, stating underlying condition last Due to (or as a consequences of)
II ©
Other significant conditions contributing to the ………………………………………
death but not related to the disease or …………………
conditions causing II ………………………………………

Manner of Death How did the injury occur?

1. Natural 2. Accident 3. Suicide 4. Homicide
5. Pending Investigation
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If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No
If yes, was there a delivery? 1. Yes 2. No

Name and signature of the Medical Attendant certifying the cause of death
Date of verification ……………………………………………
_____________________________________________________________________
(To be detached and handed over to the related of the deceased)
Certified that Shri/Smt/Km ……………………S/W/D of Shri. ……………………
R/O ………………………was admitted to this hospital on …….. and expired on
……………………………………..

Doctor ………………
(Medical Supdt.
Name of Hospita1
 Death Investigation Form
(COVID-19 confirmed cases)
Department of Health & Family Welfare, Chhattisgarh

District:
Date of filling form:
A. Details of deceased
1.Name of deceased 2.Age of deceased
3.Gender Male/Female/Other 4.District of residence
5. Postal Address
6. Place of death Covid care centre/ DCHC/DCH / Home/ Transit/Panchayat Quarantine centre/ Facility
Quarantine/ Home Quarantine

7.Date of death 8. Date of onset of

symptoms if
symptomatic
9.Name of facility/ Hospital
10.Type of facility (place where deceased was admitted at time of death) Government / Private
11. What was mode of transport to hospital / facility Self/ Government /Other
12. Number of facilities visited for treatment (including clinic, informal providers):__________
13. Date of admission to 14. On Oxygen Yes / No
hospital support
15. ICU Admission: Yes / No 16. On Ventilation Yes / No
support
17.Signs on admission
a. Temperature (degree b. Abnormal Chest X Yes/ No
Celsius) ray :
c. Respiratory Rate ___/minute d. Heart Rate ______/minute
e. BP ____mm/Hg f. Stridor: Yes / No
g: Seizure Yes / No h: Coma Yes / No
I. Redness of eye: Yes / No j. Abnormal Lung Yes / No
auscultation
18. Symptoms on admission
a. Fever/Chills Yes / No b. Sore throat Yes / No
c. Nausea/ Vomiting Yes / No d. General weakness Yes / No
e. Breathlessness Yes / No f. Headache Yes / No
g. Cough Yes / No h. Diarrhoea Yes / No
i. irritability/confusion Yes / No j. Runny nose Yes / No
19. Underlying medical condition (Select that apply)
a. COPD Yes / No h. Heart Disease Yes / No

b. Hypertension Yes / No i. Bronchitis Yes / No

c. Chronic neurological or Yes / No j. Diabetes Yes / No
neuromuscular disease

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d. Chronic Renal Disease Yes / No k. Yes / No
Immunocompromised
condition including
HIV/TB Malignancy
e. Asthma Yes / No l.Liver Disease Yes / No
f. Pregnancy Yes / No m. Other Yes / No
g,Post-partum( < 6 Yes / No n. None Yes / No
weeks)

20. Briefly summarise the case history

(Explain how the deceased may have got infected, illicit - travel history, history of contact, history of comorbidities,
surveillance of the deceased, any delay in seeking health, transport to facility or treatment, were last rites conducted
with due respect and with due infection prevention protocols)

30. Signature of the interviewer:

31. Signature of MO/Specialist/DSO / CMHO:

IMPORTANT INSTRUCTIONS-

1. It is crucial to notify all deaths of confirmed covid 19 cases. All deaths should be notified to District
and State Control and Command centre within 24 hours of death.
2. This Death Investigation Form is to be filled within 24 hours of the death and shared with the
(District/ State Surveillance Unit- email- idspssucg@gmail.com) State Control and Command centre
for Covid 19, Dept. of Health & Family Welfare, Government of Chhattisgarh.
3. If the death is at facility, then the treating doctor or Covid Nodal Officer (facility) for should fill the
form. If the death is at home/ transit then DSO / Epidemiologist should fill the form.
4. Review of all covid 19 deaths should be conducted by medical technical team of the facility and Covid
19 Control & Command team of the district.
5. Issues pertaining to medical treatment and surveillance should be discussed under leadership of
CHMO.
6. Those issues in which District Collector’s intervention is required should be discussed at review
meeting held under leadership of DC.
7. Both reviews (at CMHO level and DC level) should be conducted within one week of the death.
Minutes of review meeting should be sent to State Control and Command centre for Covid 19, Dept.
of Health & Family Welfare, Government of Chhattisgarh.
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