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North Carolina’s Violent Death
Reporting System (NC-VDRS)
Middle District PSN Training
Workshop
September 30, 2010
Agenda
• Background and history of NC-VDRS
• Key findings from NC-VDRS
– Overall Violent Death
– Suicide
– Homicide
• Q&A
Violent Deaths in the US
• 50,000 Americans died from violence in 2002
– 40,000 MVTA, 14,000 HIV
– Suicide (32,000) > Assa...
…But We Didn’t Know Enough…
• What % of women killed in DV assaults had a
restraining order against the offender?
• How ma...
What is the National Violent Death
Reporting System (NVDRS)?
1. Population-based, public health reporting system on deaths...
Currently Funded NVDRS States, 2010
Introduction to NC-VDRS
• North Carolina is one of 18 states funded by the
Centers for Disease Control and Prevention (CDC...
Data Sources
• Data are gathered from multiple
sources
–Death Certificates (SCHS)
–Medical Examiner (OCME)
–Law Enforcemen...
Types of information gathered
• Demographics (victim and suspect)
• Circumstances of the event
• Alcohol/drug use by the v...
Flow of Information for NVDRS
Occurrence of a
violent death
Medical
Examiner
State Health Dept
State agencies
Other Fed. a...
Key Findings to Date
Deaths by Manner/Intent: Resident and Occurrence Deaths
North Carolina Violent Death Reporting System, 2004-2009*
6254
354...
Percent of Deaths Due to Violence by Manner/Intent:
North Carolina Violent Death Reporting System, 2004-2008
Suicide: 61%
...
Deaths Due to Violence by Manner/Intent and Age:
North Carolina Violent Death Reporting System, 2004-2008
0
200
400
600
80...
Violent Death Rates by Manner/Intent and Age:
North Carolina Violent Death Reporting System, 2004-2008
0
2
4
6
8
10
12
14
...
Percent of Deaths Due to Violence by Race and Gender:
North Carolina Violent Death Reporting System, 2004-2008
55
41 40
60...
Violent Death Rates by Manner/Intent Sex and Race:
North Carolina Violent Death Reporting System, 2004-2008
0
5
10
15
20
2...
Percentage of Deaths From Suicides by Place of Injury :
North Carolina Violent Death Reporting System, 2004-2008
82
1 2
5
...
Percentage of Deaths From HOMICIDES by Place of Injury :
North Carolina Violent Death Reporting System, 2004-2008
62
1
16
...
Percent of Deaths by Manner and Method of Fatal Injury:
North Carolina Violent Death Reporting System, 2004-2008
68%
14%
6...
Suicide
Precipitating Circumstances For Suicide
• Recent depressed mood
• Current mental health problem/diagnosis
– If so, what wa...
Precipitating Circumstances For Suicide
• Did the person
– leave a suicide note?
– tell someone about his/her intent to co...
Percent of Suicides By Mental Health Status and Gender:
North Carolina Violent Death Reporting System, 2004-2008
49
42
36
...
Percent of Suicides by Suicide Markers and Gender:
North Carolina Violent Death Reporting System, 2004-2008
12
24
27
39
19...
Percent of Suicides by Life Stressors and Gender:
North Carolina Violent Death Reporting System, 2004-2008
38
21
28
8
12
2...
Percent of Suicides by History of Substance Abuse and Gender:
North Carolina Violent Death Reporting System, 2004-2008
15
...
Homicide
Precipitating Circumstances for
homicide
• Did the homicide
– result from an argument or conflict over money or
property?
...
Precipitating Circumstances for
homicide
• Did the homicide
– Did the homicide result from drug dealing or
illegal drug us...
Percent Homicides by Crime Related Circumstance and Gender:
North Carolina Violent Death Reporting System, 2004-2008
31
27...
Percent Homicides by Conflict Related Circumstance and Gender:
North Carolina Violent Death Reporting System, 2004-2008
61...
Percent of Homicides by Crime Related Circumstance:
North Carolina Violent Death Reporting System, 2004-2008
39
16
8
4
0
1...
Percent of Homicides by Victim Characteristics:
North Carolina Violent Death Reporting System, 2004-2008
10 10
4
12
0
10
2...
MURDER/SUICIDE
Number of Deaths and Incidents From Violence:
North Carolina Violent Death Reporting System, 2004-2008
1271067
2873
5383
0...
Percent of Murder/Suicide Victims by Gender:
North Carolina Violent Death Reporting System, 2004-2008
Female(78%)
Male
(22...
Percent of Murder/Suicide Perpetrators by Gender:
North Carolina Violent Death Reporting System, 2004-2008
Female(5%)
Male...
Percent Murder/Suicide Victims by Race:
North Carolina Violent Death Reporting System, 2004-2008
63
26
3
8
0
10
20
30
40
5...
Percent Murder/Suicide Perpetrators by Race:
North Carolina Violent Death Reporting System, 2004-2008
66
21
2
11
0
10
20
3...
Percent Murder/Suicide Victims/Perp by Race and Gender:
North Carolina Violent Death Reporting System, 2004-2008
22
69
27
...
ALCOHOL USE SUSPECTED
Suspected Alcohol Use by Manner of Death:
North Carolina Violent Death Reporting System, 2004-2008
28
33
42
25
18
0
5
10
1...
Suspected Alcohol Use by Manner of Death and Gender:
North Carolina Violent Death Reporting System, 2004-2008
22
19
0
23
0...
QUESTIONS
North Carolina Violent Death
Reporting System (NC-VDRS)
Tammy Norwood, Program Manager
NC Injury & Violence Prevention Bra...
2010 Middle District PSN Training (09-30-10)
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2010 Middle District PSN Training (09-30-10)

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  • Good Morning, I am Tammy Norwood, Program Manager for the North Carolina Violent Death Reporting System. I am very excited to have this opportunity to share some information with you about our program
  • I will cover the background and history of the North Carolina Violent Death Reporting System as well as the National System. Look at some of the key findings to date, discuss overall violent death, suicide and homicide. Then answer any questions
  • What did we know prior to the NVDRS, Violence was pervasive in our society. It affects the young and the old, the rich and the poor. Violence can be directed at one’s self, resulting in suicide or directed at others resulting in homicide, legal intervention, or even unintentional deaths from firearm injuries. In 2002, over 50,000 Americans died from violence in the US with 32,000 of those deaths being suicides. Homicide and suicide were affecting younger people at greater rates, homicide was the 2nd leading cause of death for those 15-24 and suicide the second leading cause of death for 15-34.
  • We could tell you who was dying but we really couldn’t answer the why. We just didn’t have a good understanding of the circumstance leading up to these deaths. The kind of information that is really important when putting prevention programs in place. So, the Centers for Disease Control was challenged with developing a surveillance system with the purpose of capturing information on these deaths.
  • The CDC developed the National Violent Death Reporting System which would be a population based surveillance system. States receiving funding collect information on all deaths from violence that occur in the state. The goal of the system was to provide more timely detailed data on violent death incidents. The system developed was based on FARS. Fatality Analysis Reporting System (FARS) began collecting crash data back in 1975
  • The CDC funded the first round of states in 2002. Here is a map showing the 18 states who are currently funding to collect this information.
  • North Carolina received funding in 2003 and began collecting information on violent deaths in 2004. Information is collected on suicide, homicide, unintentional firearm deaths, deaths of undetermined intent and legal intervention. Our system is housed in the state health department. In the injury and violence prevention branch.
  • Our primary data sources include death certificates, medical examiner. including autopsy and toxicology findings, law enforcement and NC-IBRS data provided by the SBI. The VDRS is a very unique system. It is a source based system allowing the collection of information from each source to be captured in separate data tables within the system. This allows us to look at information from each source separately as will as collectively. We have often been asked why not just get the information from one source. In order to get a better understanding of these deaths, we need information from all three sources. The death certificate tells us who died, the medical examiner provides information on caused the death, injuries, weapons, toxicology. Law enforcement provides the details of what occurred prior to the death, who was involved, where the incident took place and often why.
  • We gather various pieces of information from our data sources on both victim and suspects. We look at not only the demographics but where the incident occurred, weapons used, the circumstances leading up to the incident and relationships between those involved in the incident.
  • This chart demonstrates how information flows into our system. So, a death occurs, is reported to the medical examiner who issues a death certificate that is certify by the state. We receive the information from DC as well as ME, we later contact law enforcement.
  • Now I would like to share a few of our findings to date. As I stated earlier, we started collecting information in 2004 so most of the results I will talk about today includes 2004-2008. We have preliminary numbers for 2009 and have began data collection for 2010.
  • I included this slide to give you an idea of the number of violent deaths that have occurred in our state since 2004. Keep in mind the 2009 are preliminary and we have not included 2010. This shows total number of deaths between 2004-2009 by manner., there were over 10,000 deaths that occurred in NC. You will see that we have listed resident deaths as well as occurent deaths. We collected information on every death that occurs in NC regardless of residency. 97% of all victims of violent deaths are residents of our state.
  • In North Carolina there are over 1800 deaths from violence each year. 61% of those deaths are classified as suicide and 35% homicide. The remaining categories account for a very small percentage. Most people are very shocked to learn that there are about one-and-a-half times more suicides than homicides occurring every year in our state. In the US the patterns are very similar as well as other states.
  • Deaths from violence differ markedly by manner of death, age, race and sex. The highest number of suicides occurred between the ages of 25-54 while the highest number of homicides occurred between 20-44. When we look at the rate per 100,000 we get a slightly different picture.
  • When we look at the rate per 100,000 we get a slightly different picture. The 20-24 year old age bracket are more likely than any other age group to die from homicide. On the other hand, people aged 45 years and older are more likely to die from suicide.
  • Men make up over 70% of all violent deaths and. For homicide men make up almost 80%
    55 percent of all male homicide victims were black, while 90 percent of all male suicide victims were white. Overall, 89% of all suicide victims were white while 51% of all homicide victims were black.
  • Violence affects racial groups differently and when we look at rates we see that although American Indian men made up only 3% of the homicide victims they are at highest risk to die from homicide with a rate of nearly 40 per 100,000. Followed by Black men with a rate of 36. Overall, whites are nearly 3 times more likely than blacks to die from suicide. Blacks are 4 times more likely to die from homicide than whites.
  • Overall firearms were the method most often used in all violent deaths. However the method used differed by manner. Poison was the second most common method used for suicide while sharp instrument was the second most common method used in homicide. We also see a difference when looking at sex, the method of suicide differed between men and women with poisonings more common in female suicide than male.
  • When trying to address the precipitating circumstance that lead up to each suicide we capture ….
  • Did the person leave a note, tell someone his/her intent, was there a history of attempts. Was there a crisis within two weeks, was there a physical health problem relevant to the suicide?
  • Almost half of the men and women were reported by a family member or friend as having been in a depressed mood prior to their suicide. Two thirds of the women who died by suicide had a medical history of depression or other type of mental illness. Over 60% were receiving treatment.
  • Here when looking at intent we see that women are more likely than men to have a history of attempts. This most likely goes back the method chosen based on gender.
  • 38% of men who died by suicide were reported to have a crisis within 2 weeks. This could have occurred prior or anticipation of an event. The crisis was most often an intimate partner problem, this could be argument, break up, divorce. We see from 2004-2008 only 8% of men who died by suicide were reported to have job problems. We are very interested in seeing how the numbers for job loss, financial problems, and foreclosure/eviction change in the coming years. We have already noted changes in how often job problems or listed or current occupation listed as unemployed.
  • Alcohol abuse and substance abuse can be reported by friends and family or self perceived by the victim. Other substance includes prescription medication.
  • We have the ability to capture
  • 31 percent of homicides involving male victims was precipitated by another crime, and in 27% of the incidents the crime was in progress. We know that our gang data is definitely an undercount.
  • When looking at conflict related circumstance start seeing clear difference. 61% of incidents involving male victims were related to an argument. Over 52 percent of the homicides involving females were related to intimate partner violence.
  • When we break down the type of crimes taking place those often were robbery followed by drug trade.
  • These are just some of the victim characteristics.
  • Talk a little bit about Murder/Suicide.
  • I mentioned earlier that our system is a relational database. We are able to look at all victims and suspects. Overall most of the incidents occurring in our state involve a single victim. This give you an idea of what we are capable of capturing. There were 127 incidents classified as murder/suicide.
  • Of those 125 incidents 81% of the victims were female while 19 percent were male.
  • When we look at the perpetrator in those 127 incidents 95% were male.
  • Looking at race, 62% were white
  • And 62% of the perpetrators were white.
  • Toxicology
  • How many victims in each manner were suspected of using alcohol prior to incident. 42% of legal intervention victims were suspected of using alcohol.
  • When we break down by gender and manner. 38% of all male homicide victims were suspected of using alcohol.
  • We really have the ability to capture over 300 variables for each violent incident. I shared a small portion of the information with you today. Here are a few of the publications that can be found on our website.
  • Thanks again. Please feel free to contact me if you additional question.
  • Transcript of "2010 Middle District PSN Training (09-30-10)"

    1. 1. North Carolina’s Violent Death Reporting System (NC-VDRS) Middle District PSN Training Workshop September 30, 2010
    2. 2. Agenda • Background and history of NC-VDRS • Key findings from NC-VDRS – Overall Violent Death – Suicide – Homicide • Q&A
    3. 3. Violent Deaths in the US • 50,000 Americans died from violence in 2002 – 40,000 MVTA, 14,000 HIV – Suicide (32,000) > Assaults (18,000) • Homicide and suicide affect young persons – Homicide 2nd leading cause of death – persons 15-24 years – Suicide 2nd leading cause of death – persons 15-34 years • Elderly have high suicide rates • Violence greater impact on some populations groups
    4. 4. …But We Didn’t Know Enough… • What % of women killed in DV assaults had a restraining order against the offender? • How many drug-related homicides are there in the US each year? • How often do multiple homicides occur? • What % of youth suicide victims are intoxicated at the time they kill themselves? • How many homicides involves the use of an assault weapon? • What life crisis commonly precedes a suicide? • How many men kill themselves after killing their partner?
    5. 5. What is the National Violent Death Reporting System (NVDRS)? 1. Population-based, public health reporting system on deaths from violence managed by the CDC ● Funding through competitive application ● Ultimate goal to fund 50 states and territories 2. Data are collected by states and sent to CDC ● Data on homicides, suicides, and deaths from unintentional firearm, legal intervention and undetermined intent obtained from multiple sources ● Personal identifiers are removed 3. Provides timely and detailed data on incidents where someone is killed by violence, including victims, suspects, weapons, circumstances and their inter-relationships.
    6. 6. Currently Funded NVDRS States, 2010
    7. 7. Introduction to NC-VDRS • North Carolina is one of 18 states funded by the Centers for Disease Control and Prevention (CDC) • Housed in the State Health Department • Collect detailed information on deaths from violence – Suicide – Homicide – Unintentional Firearm – Deaths of undetermined intent – Legal Intervention
    8. 8. Data Sources • Data are gathered from multiple sources –Death Certificates (SCHS) –Medical Examiner (OCME) –Law Enforcement (Local) –NC-IBRS(SBI)
    9. 9. Types of information gathered • Demographics (victim and suspect) • Circumstances of the event • Alcohol/drug use by the victim • Type of location where the event happened • Type of weapon used • Relationship between the victim and suspect
    10. 10. Flow of Information for NVDRS Occurrence of a violent death Medical Examiner State Health Dept State agencies Other Fed. agencies General public Researchers Law enforcement Case Info (- identifiers) Death certificate NVDRS (at CDC) NC-VDRS Analysis Files (+) Data Re-release Policy Certificate of Confidentiality IRB approval for research No restrictions for aggregate data
    11. 11. Key Findings to Date
    12. 12. Deaths by Manner/Intent: Resident and Occurrence Deaths North Carolina Violent Death Reporting System, 2004-2009* 6254 3549 80 94 297 6421 3677 86 97 306 0 1000 2000 3000 4000 5000 6000 7000 Suicide Homicide Unintentional Firearm Legal Intervention Undetermined Intent Number of Deaths Total resident deaths = 10,274 Total occurrence deaths = 10,587 Solid bars: resident deaths Striped bars: occurrence deaths *2009 data are provisional
    13. 13. Percent of Deaths Due to Violence by Manner/Intent: North Carolina Violent Death Reporting System, 2004-2008 Suicide: 61% Homicide: 35% Unintentional Firearm: 1% Legal Intervention: 1% Undetermined Intent: 3%
    14. 14. Deaths Due to Violence by Manner/Intent and Age: North Carolina Violent Death Reporting System, 2004-2008 0 200 400 600 800 1000 1200 1400 <1 '1-4 '5-9 '10-1415-1920-2425-3435-4445-5455-6465-7475-84 85+ Number of Deaths Suicide Homicide
    15. 15. Violent Death Rates by Manner/Intent and Age: North Carolina Violent Death Reporting System, 2004-2008 0 2 4 6 8 10 12 14 16 18 20 <1 '1-4 '5-9 '10-1415-1920-2425-3435-4445-5455-6465-7475-84 85+ Rates Per 100,000 Suicide Homicide
    16. 16. Percent of Deaths Due to Violence by Race and Gender: North Carolina Violent Death Reporting System, 2004-2008 55 41 40 60 90 6 92 8 0 10 20 30 40 50 60 70 80 90 100 Black Male White Male Black Female White Female Percent of Deaths Homicide Suicide
    17. 17. Violent Death Rates by Manner/Intent Sex and Race: North Carolina Violent Death Reporting System, 2004-2008 0 5 10 15 20 25 30 35 40 Rates per 100,000 Homicide Suicide American Indian Male American Indian Female Black Male Black Female White Male White Female Other Male Other Female
    18. 18. Percentage of Deaths From Suicides by Place of Injury : North Carolina Violent Death Reporting System, 2004-2008 82 1 2 5 1 4 4 1 0 0 10 20 30 40 50 60 70 80 90 Suicide Percent of Deaths by Place of Injury House/Apartment Residential Institution Highway/Road Motor Vehicle Recreational Area Commercial Area Natural Area Other Unknown
    19. 19. Percentage of Deaths From HOMICIDES by Place of Injury : North Carolina Violent Death Reporting System, 2004-2008 62 1 16 6 1 9 3 1 2 0 10 20 30 40 50 60 70 Homicide Percent of Deaths by Place of Injury House/Apartment Residential Institution Highway/Road Motor Vehicle Recreational Area Commercial Area Natural Area Other Unknown
    20. 20. Percent of Deaths by Manner and Method of Fatal Injury: North Carolina Violent Death Reporting System, 2004-2008 68% 14% 6% 0% 5% 3%4% 60% 1% 0% 17% 0% 3% Firearm Sharp Inst Blunt Poison Hanging Unarmed OtherHomicide Suicide
    21. 21. Suicide
    22. 22. Precipitating Circumstances For Suicide • Recent depressed mood • Current mental health problem/diagnosis – If so, what was the diagnosis? – Was the person under treatment for his/her MH problem? – Has the person ever been treated for a MH problem? • Alcohol dependence • Substance abuse problem
    23. 23. Precipitating Circumstances For Suicide • Did the person – leave a suicide note? – tell someone about his/her intent to commit suicide? – have a history of suicide attempts? – experience some type of crisis in the past two weeks? – have a physical health problem that was relevant to the suicide?
    24. 24. Percent of Suicides By Mental Health Status and Gender: North Carolina Violent Death Reporting System, 2004-2008 49 42 36 41 47 67 62 66 0 10 20 30 40 50 60 70 80 90 100 Reported current depressed mood MD Dx'd current mental illness Current Treatment Ever Treated Percent of Deaths Males Females
    25. 25. Percent of Suicides by Suicide Markers and Gender: North Carolina Violent Death Reporting System, 2004-2008 12 24 27 39 19 30 0 10 20 30 40 50 60 70 80 90 100 History Of attempts Disclosed Intent Left a note Percent of Deaths Males Females
    26. 26. Percent of Suicides by Life Stressors and Gender: North Carolina Violent Death Reporting System, 2004-2008 38 21 28 8 12 27 18 21 3 4 0 10 20 30 40 50 60 70 80 90 100 Crisis within 2 Weeks Physical Health Problem Intimate Partner Problem Job Problem Legal Problem Percent of Deaths Males Females
    27. 27. Percent of Suicides by History of Substance Abuse and Gender: North Carolina Violent Death Reporting System, 2004-2008 15 1212 16 0 10 20 30 40 50 60 70 80 90 100 Alcohol Other Substance Percent of Deaths Males Females
    28. 28. Homicide
    29. 29. Precipitating Circumstances for homicide • Did the homicide – result from an argument or conflict over money or property? – result from jealousy or distress over an intimate partner’s relationship or suspected relationship with another person? – involve a conflict between current or former intimate partners? – involve other interpersonal conflict, such as abuse, insult, grudge, or personal revenge?
    30. 30. Precipitating Circumstances for homicide • Did the homicide – Did the homicide result from drug dealing or illegal drug use? – Was the homicide gang-related? – Was the homicide precipitated by another serious crime (e.g., drug dealing, robbery, rape)If so, what type of crime? – Was the other crime in progress when the homicide occurred? – Did the death involve justifiable self-defense?
    31. 31. Percent Homicides by Crime Related Circumstance and Gender: North Carolina Violent Death Reporting System, 2004-2008 31 27 14 3 26 22 9 0 0 10 20 30 40 50 60 70 80 90 100 Precipitated By another Crime Crime In Progress Drug Involvement Gang Related Percent of Deaths Males Females
    32. 32. Percent Homicides by Conflict Related Circumstance and Gender: North Carolina Violent Death Reporting System, 2004-2008 61 10 4 12 31 52 2 2 0 10 20 30 40 50 60 70 80 90 100 Argument Initmate Partner Violence Jealousy Victim Used a Weapon Percent Males Females
    33. 33. Percent of Homicides by Crime Related Circumstance: North Carolina Violent Death Reporting System, 2004-2008 39 16 8 4 0 10 20 30 40 50 60 70 80 90 100 Robbery Drug Trade Rape, Sexual Assault Motor Vehicle Theft Percent of Deaths
    34. 34. Percent of Homicides by Victim Characteristics: North Carolina Violent Death Reporting System, 2004-2008 10 10 4 12 0 10 20 30 40 50 60 70 80 90 100 Victim Used a Weapon Justifiable Self Defense Victim Was a Bystander Victim was assisting crime victim Percent of Deaths
    35. 35. MURDER/SUICIDE
    36. 36. Number of Deaths and Incidents From Violence: North Carolina Violent Death Reporting System, 2004-2008 1271067 2873 5383 0 1000 2000 3000 4000 5000 6000 Single Suicide Single HomicideMutiple Suicide Multiple Homicide Murder/Suicide Number of Deaths
    37. 37. Percent of Murder/Suicide Victims by Gender: North Carolina Violent Death Reporting System, 2004-2008 Female(78%) Male (22%)
    38. 38. Percent of Murder/Suicide Perpetrators by Gender: North Carolina Violent Death Reporting System, 2004-2008 Female(5%) Male (95%)
    39. 39. Percent Murder/Suicide Victims by Race: North Carolina Violent Death Reporting System, 2004-2008 63 26 3 8 0 10 20 30 40 50 60 70 White Black American Indian Hispanic Percent of Deaths
    40. 40. Percent Murder/Suicide Perpetrators by Race: North Carolina Violent Death Reporting System, 2004-2008 66 21 2 11 0 10 20 30 40 50 60 70 White Black American Indian Hispanic Percent of Deaths
    41. 41. Percent Murder/Suicide Victims/Perp by Race and Gender: North Carolina Violent Death Reporting System, 2004-2008 22 69 27 62 6 8 3 4 65 0 83 10 17 2 0 22 0 10 20 30 40 50 60 70 80 90 Black Male White Male Black Female White Female Hispanic Male Hispanic Female American Indian Male American Indian Female Percent of Deaths Victim Perp.
    42. 42. ALCOHOL USE SUSPECTED
    43. 43. Suspected Alcohol Use by Manner of Death: North Carolina Violent Death Reporting System, 2004-2008 28 33 42 25 18 0 5 10 15 20 25 30 35 40 45 Suicide Homicide Legal Intervention Undetermined IntentUnintentional Firearm Percent of Deaths
    44. 44. Suspected Alcohol Use by Manner of Death and Gender: North Carolina Violent Death Reporting System, 2004-2008 22 19 0 23 0 0 5 10 15 20 25 30 35 40 Suicide Homicide Legal Intervention Undetermined IntentUnintentional Firearm Percent of Deaths 30 38 42 27 20 0 5 10 15 20 25 30 35 40 45 Suicide Homicide Legal Intervention Undetermined IntentUnintentional Firearm Percent of Deaths Females Males
    45. 45. QUESTIONS
    46. 46. North Carolina Violent Death Reporting System (NC-VDRS) Tammy Norwood, Program Manager NC Injury & Violence Prevention Branch 1915 Mail Service Center Raleigh, NC 27699-1915 919-707-5432 Tammy.norwood@dhhs.nc.gov http://www.injuryfreenc.ncdhhs.gov/
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