FORM 4A

  
...
  

PERSONAL INFORMATION


                      


  


                        


CAUSE OF DEATH

(Avoid causes listed as mode of dying, complete the underlying cause of death sequence)

Immediate Cause (due to or as a consequence of)
            ICD-10 DESCRIPTION
Years
Months
Days
Hours
Minutes

Antecedent Cause (due to or as a consequence of)








Years
Months
Days
Hours
Minutes

  

MANNER OF DEATH*

  

DOCTOR INFORMATION



  

Instructions to Registered Medical Practitioners filling Form 4A

   1. MCCD should be entered only by the Registered Medical Practitioners who attended the Death during the last illness.

   2. Only Cause of Death must be entered in Part 1 & Comorbidities in Part 2. The following must be avoided as Cause of Death.

    Avoid mentioning Manner of Death ( Natural death, Brought Dead, Pending investigation)

    Avoid mentioning Multiple cause of Death in Immediate/Antecedent/Underlying Cause of death columns ( Eg : Diabetes/Hypertension/CAD). Only single cause must be mentioned in these columns.

    Avoid Abbreviations (RTA, CABG, CAD etc)