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Death with Dignity Forms via PDF

Compliance Forms

( ORS 127.800 - 127.897 )

  •  Patient Request Form​  - Revised 03/2014
  • ​​ Attending Physician Form  - Revised 11/2006​
  • ​or  Attending Physician Short Form - Revised 11/2006
    Please Note: All information required in the standard two-page Attending Physician Form must be included in accompanying copies of the patient's chart notes. (See Attending Physician Form.) Most physicians use the two-page form to avoid call-backs for missing data items. 
  •  Consulting Physician Form  - Revised 11/2006
  •  Psychiatrist/Psychologist Form - Revised 11/2006
  •  Pharmacy Dispensing Record Form  - Revised 11/2006
  •  

    Surveillance Forms

  • Attending Physician Follow-Up Form - Revised 04/2010
    Data collected from follow-up interviews with physicians. This document may be completed by the attending physician in lieu of a follow-up interview. NOTE: Older versions of this form will not longer be accepted by OHA after June 1, 2010.​
  •  Chronology and Death Certificate Extract Form - Revised 10/2006
    Completed by OHA Staff. Data collected from death certificates and physician reporting forms.
  •  

    The envelope used to return all forms should be marked as CONFIDENTIAL and mailed to:

    Oregon Health Authority
    Center for Health Statistics
    PO Box 14050
    Portland OR 97293-0050
    Attn: Vivian Siu


    Hard copies of the rules and reporting forms can be obtained by emailing dwda.info@state.or.us or contacting us at:

    Oregon Health Authority
    Center for Health Statistics
    PO Box 14050
    Portland OR 97293-0050
    Attn: Vivian Siu
    Phone (971) 673-1150 ​​​​​​​​​​​​​​