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pdfCJ-11A ADDENDUM
OMB No. 1121-0249 Approval Expires 12/31/2012
FORM CJ-11A
(10-13-2009)
RETURN TO: State reporting coordinator
(See form CJ-11 for a national listing, or call the
Bureau of Justice Statistics at 202-307-0765.)
What was the name of the deceased?
Last
2.
8.
First
Middle initial
AM PM
Month
Day
, 2009
City, State, Zip
What law enforcement agency was involved?
08 Other — Specify
ORI Number
What was the deceased’s date of birth?
Month
6.
Day
10. What was the cause of death?
Year
What was the deceased’s sex?
01 Male
02 Female
7.
Homicide by law enforcement officer(s)
Other homicide
Suicide
Accidental injury to self
Accidental injury caused by others
Accidental alcohol/drug intoxication — Specify type
07 Illness — Specify illness
Name
5.
Yes, results are available
Yes, results pending — Skip to item 11.
No, evaluation pending — Skip to item 11.
No, evaluation not planned
What was the manner of death?
01
02
03
04
05
06
Where did the event causing the death occur?
Street address
4.
9.
Death number
out of period total of
as reported on form CJ-11
Has a medical examiner or coroner conducted an
evaluation to determine the official cause of death?
01
02
03
04
What was the time and date of death?
:
3.
DRAFT
Reporting Period (Mark only one.)
Quarter 1 (January 1 — March 31)
Quarter 2 (April 1 — June 30)
Quarter 3 (July 1 — September 30)
Quarter 4 (October 1 — December 31)
State
1.
ARREST-RELATED DEATH REPORT, 2009
11. Had charges been filed against the deceased at the
time of death?
What was the deceased’s race/ethnic origin?
01
02
03
04
05
06
White (not of Hispanic origin)
Black, or African American (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander
(not of Hispanic origin)
07 Two or more races (not of Hispanic origin)
08 Additional categories in your information system—Specify
09 Not known
01
02
03
04
Yes
No — charges not filed, but intended
No — probation/parole revocation
No — medical/mental health assistance call
12. What were the most serious offenses with which the
deceased was being charged at the time of death?
a.
b.
c.
Burden Statement
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. The burden of
this collection is estimated to average 5 minutes per response, including reviewing instructions, searching existing data sources, gathering necessary data, and
completing and reviewing this form. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for reducing this burden, to the
Director, Bureau of Justice Statistics, 810 Seventh Street, N.W., Washington, DC 20531.
Name of deceased
13. Did the deceased die from a medical condition or from
injuries sustained during the arrest process?
01
02
03
08
Medical condition only (e.g., heart attack)
Injuries only
Both medical condition and injuries
Don’t know
14. If the deceased died from arrest-related injuries, how were
these injuries sustained? C Mark (x) all that apply
01
02
03
04
05
08
09
Inflicted by law enforcement officers at crime/arrest scene
Inflicted by others at crime/arrest scene
Inflicted by law enforcement officers during transit/booking
Self-inflicted — Accidental
Self-inflicted — Suicide
Don’t know
Not applicable
15. Were any of the following used during the arrest process?
01 Yes — Mark (x) all that apply
01
02
03
04
05
Handcuffs
Leg shackles
Pepper spray, mace
Conducted energy device (e.g., taser, stun-gun)
Other device — Specify
02 No
08 Don’t know
16. At any time during the arrest/incident, did the
deceased — Mark (x) all that apply
01
02
03
04
05
06
07
Appear intoxicated (either alcohol or drugs)?
Exhibit any mental health problems?
Verbally threaten the officer(s) involved?
Resist being handcuffed or arrested?
Attempt to escape/flee from custody?
Attempt to grab, hit or fight with the officer(s) involved?
None of the above
17. During the arrest process, did the deceased do any of the
following — Mark (x) all that apply
01 Carry or possess a weapon? — Specify weapon(s)
02 Use a weapon to threaten the officer(s)? — Specify
03 Use a weapon to threaten other persons? — Specify
04 Use a weapon to assault the officer(s)? — Specify
05 Use a weapon to assault other persons? — Specify
06 None of the above
18. What type of weapon(s) caused the death? — Mark (x) all
that apply
01
02
03
04
Handgun
05 Conducted energy device
Rifle/shotgun
06 Other weapon — Specify
Firearm, unspecified
Nightstick or baton
07 None
19. Where did the deceased die?
01
02
03
04
05
06
At booking center/police lockup — Complete items 20-23.
At the crime/arrest scene
At medical facility
— Form complete
En route to medical facility
En route to booking center/police lockup
Elsewhere — Specify location
08 Don’t know — Complete items 20-23.
20. What was the time and date of the deceased's entry into
the law enforcement facility where the death occurred?
:
AM PM
Month
Day
, 2009
21. At the time of entry into the law enforcement facility, did
the deceased — Mark (x) all that apply
01
02
03
04
Appear intoxicated (either alcohol or drugs)?
Exhibit any mental health problems?
Exhibit any medical problems?
None of the above
22. If death was an accident or homicide, who caused the
death?
01
02
03
04
Deceased
Other detainees
Law enforcement/correctional staff
Other persons — Specify
08 Don’t know
09 Not applicable; cause of death was suicide,
intoxication or illness
23. If death was an accident, homicide or suicide, what was
the means of death? — Mark (x) all that apply
01
02
03
04
05
06
Firearm
Blunt instrument
Knife, cutting instrument
Hanging, strangulation
Drug overdose
Other — Specify
08 None of the above
09 Not applicable; cause of death was intoxication or
illness
NOTES
| File Type | application/pdf |
| File Title | CJ-11A 2009 final.fm |
| Author | sabolw |
| File Modified | 2009-12-18 |
| File Created | 2005-08-26 |