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pdfOMB No. 1121-0249 Approval Expires 12/31/2012
FORM CJ-9
(10-13-2009)
U.S. DEPARTMENT OF JUSTICE
DEATHS IN CUSTODY — 2009
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT
QUARTERLY REPORT ON INMATES
UNDER JAIL JURISDICTION
RTI International
Crime, Violence, and Justice
Research Program
DATA SUPPLIED BY
TITLE
NAME
OFFICIAL
ADDRESS
Number and street or P.O. box/Route number
TELEPHONE
Area Code
Number
City
FAX
NUMBER
State
Area Code
ZIP Code
Number
E-MAIL
ADDRESS
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)
DRAFT
(Please correct any error in name, mailing address, and ZIP Code)
What deaths should be reported?
• INCLUDE deaths of ALL persons —
CONFINED in your jail facilities, whether housed
under your own or another jurisdiction;
UNDER YOUR JURISDICTION but housed in special
jail facilities (e.g., medical/treatment/release centers,
halfway houses, and work farms); or on transfer to
treatment facilities;
UNDER YOUR JURISDICTION but out to court;
WHILE IN TRANSIT to or from your facilities while
under your jurisdiction.
• EXCLUDE deaths of ALL persons —
CONFINED in facilities operated by two or more
jurisdictions or those held in privately operated jails.
UNDER YOUR JURISDICTION but in non-residential
community-based programs run by your jails (e.g.,
electronic monitoring, house arrest, community
service, day reporting, work programs).
UNDER YOUR JURISDICTION but on AWOL, escape,
or long-term transfer to other jurisdiction
IN THE PROCESS OF ARREST by your agency,
but not yet booked into your jail facility.
During the reporting quarter marked above, how many
persons died while under the supervision of your local
jail jurisdiction?
Number of deaths
Instructions:
• IF NO DEATHS, please disregard.
• IF A DEATH OCCURRED, complete a LOCAL JAIL
INMATE DEATH REPORT. Please complete items 1
through 16 for each inmate death.
• If more than 1 death reported above, make copies of
pages 2 and 3 for each additional death.
• Return this quarterly report and each associated
LOCAL INMATE DEATH REPORT by FAX or MAIL
within 30 days of the end of each quarter.
• FAX (TOLL-FREE): 1-888-###-####.
• MAIL: RTI International, 3040 Cornwallis Road, P.O. Box
12194, Research Triangle Park, NC 27709-2194
• If you need assistance, call Chris Ellis of RTI International
toll-free at 1-800-###-####, or
e-mail [email protected].
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
for jurisdictions reporting zero deaths and 30 minutes per each reported death, 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, NW, Washington, DC 20531. Do not send your completed
form to this address.
DRAFT
LOCAL JAIL INMATE DEATH REPORT
7.
INMATE DEATH #
1.
For what offense(s) was the inmate being held?
OUT OF QUARTERLY TOTAL OF
What was the inmate’s name?
Last
First
a.
Ml
b.
2.
On what date did the inmate die?
Month
Day
c.
Year
2 0 0 9
d.
3.
What was the inmate’s date of birth?
Month
Day
e.
Year
8.
4.
• For persons with more than one status, report the
status associated with the most serious offense.
What was the inmate’s sex?
01
02
03
04
01 Male
02 Female
5.
What was the inmate’s race/ethnic origin?
01
02
03
04
05
06
What was the inmate’s legal status at time of death?
9.
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
Convicted — new court commitment
Convicted — returned probation/parole violator
Unconvicted
Other — Specify
Since admission, did the inmate ever stay overnight in a
mental health observation unit or an outside mental
health facility?
01 Yes
02 No
08 Don’t know
Hispanic origin)
07 Two or more races (not of Hispanic origin)
08 Additional categories in your information system—
10. Where did the inmate die?
Specify
01
02
03
04
05
06
07
08
09 Not known
6.
On what date had the inmate been admitted to a
facility under your jail jurisdiction?
Month
Day
FORM CJ-9 (10-5-2009)
Year
Page 2
In general housing within jail facility or on jail grounds
In segregation unit
In special medical unit/infirmary within jail facility
In special mental health services unit within jail facility
In medical center outside jail facility
In mental health center outside jail facility
While in transit
Elsewhere — Specify
DRAFT
Name of deceased inmate
11. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, post-mortem
exam, or review of medical records) available in order to establish an official cause of death?
01 Yes — Complete items 12 through 16.
02 Evaluation complete, results are pending — Skip remaining items; you will be contacted later for those data.
03 No such evaluation is planned — Complete items 12 through 16.
15. When did the incident (e.g., accident, suicide
or homicide) causing the death occur?
12. What was the cause of death?
01 Illness
01
02
03
04
• Exclude AIDS-related deaths.
Specify illness
02 Acquired Immune Deficiency Syndrome (AIDS)
03 Accidental alcohol/drug intoxication — Specific type
Morning (6 a.m. to noon)
Afternoon (noon to 6 p.m.)
Evening (6 p.m. to midnight)
Overnight (midnight to 6 a.m.)
09 Not applicable — cause of death was illness,
intoxication, or AIDS-related
16. Where did the incident (e.g., accident, suicide
or homicide) causing the death take place?
04 Accidental injury to self — Describe events
01 In the jail facility or on jail grounds — Specify
a. In the inmate’s cell/room
b. In a temporary holding area/lockup
c. In a common area within the facility (e.g., yard,
05 Accidental injury by other (e.g., vehicular accidents
during transport) — Describe events
06 Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) – Describe events
d.
e.
f.
g.
07 Homicide committed by other inmate(s)
08 Homicide incidental to use of force by staff —
Describe events
library, cafeteria, day room, recreational area, or
workshop)
In a segregation unit
In special medical unit/infirmary
In special mental health services unit
Elsewhere within jail facility — Specify
02 Outside the jail facility (e.g., while on work release
09 Other causes — Specify causes
13. Was the cause of death the result of a pre-existing medical
condition or did the inmate develop the condition after
admission?
or on work detail, under community supervision,
or in transit)
03 Elsewhere — Specify
09 Not applicable — cause of death was illness,
intoxication, or AIDS-related
• If multiple medical conditions caused the death,
mark “01” if any of the conditions were
pre-existing.
01
02
08
09
Notes
Pre-existing medical condition
Deceased developed condition after admission
Could not be determined
Not applicable — cause of death was accidental
injury, intoxication, suicide, or homicide
14. Had the deceased been receiving treatment for the medical
condition after admission to your correctional facilities?
• Exclude emergency care provided at time of death.
Yes
01
02
03
04
No
07
07
07
07
Don’t know
08 Evaluated by physician/medical staff
08 Had diagnostic tests (e.g. x-rays, MRI)
08 Received medications
08 Received treatment/care other than
medications
05 07 08 Had surgery
06 07 08 Confined in special medical unit
09 Not applicable — cause of death was accidental
injury, intoxication, suicide, or homicide
FORM CJ-9 (10-13-2009)
Page 3
| File Type | application/pdf |
| File Title | CJ-9 2009-final.fm |
| Author | sabolw |
| File Modified | 2009-12-18 |
| File Created | 2005-08-26 |