CJ-9A; CJ-10A; CJ- 2012 Annual Sum. on Inmates - Jail Juris.; 2012 Annual S

OMB No. 1121-0249 Approval Expires MO/DAY/YEAR

DEATHS IN CUSTODY—2012
ANNUAL SUMMARY ON INMATES
UNDER JAIL JURISDICTION

Form CJ-9A

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
IF YOUR JURISDICTION DID NOT HAVE A DEATH IN CALENDAR YEAR 2012:


Complete this form and return it to RTI International. Once you complete EVERY question, your submission will be
complete for 2012.

IF YOUR JURISDICTION DID HAVE ONE OR MORE DEATHS IN CALENDAR YEAR 2012:



Please ensure that you have completed a 2012 CJ-9 (individual death report) form for each death reported.
If you need additional CJ-9 forms, please go to the DCRP Web site (https://bjsdcrp.rti.org), call 1-800-344-1387, or
send an e-mail to [email protected].

General Information
Please submit your completed form within 30 days of receipt. You may submit your annual summary in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
E-MAIL: [email protected]

MAIL: RTI International, Attn: Data Capture
Project Number: 0212335.001.302.200
PO Box 12194
Research Triangle Park, NC 27709-2194

FAX (TOLL-FREE): 1-866-800-9179
If you need assistance, contact Kim Aspinwall of RTI International toll-free at 1-800-344-1387 or [email protected].

What facilities are included in this data collection?
INCLUDE…
 Confinement facilities usually administered by a local law
enforcement agency, intended for adults but sometimes holding
juveniles

EXCLUDE…
 Facilities that are exclusively used as temporary holding or
lockup facilities, where inmates are generally held for less than
72 hours and not held beyond arraignment

 All jails and city/county correctional centers that hold inmates
beyond arraignment. Report data on all inmates, including those
held in separate holding or lockup areas within your facility

 Privately operated jails and facilities operated by two or more
jurisdictions (i.e., multi-jurisdictional facilities; these jails will be
contacted directly for data on deaths in their custody)

 Special jail facilities (e.g., medical/treatment/release centers,
halfway houses, and work farms)

 Deaths of persons in the process of arrest by your agency if
they have not yet been booked into your jail facility. Arrestrelated deaths should be reported using a CJ-11A form

 Inmates held for other jurisdictions, including federal authorities,
state prison authorities and other local jail jurisdictions

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.

form to this address.
«AGENCY ID»

INMATE COUNTS AND DEATHS

1. How many males and females under the supervision of
your jail jurisdiction were confined in your jail facilities on
December 31, 2012?

When exact numeric answers are not available, provide
estimates and mark () in the box beside each figure.

INCLUDE:




Persons on transfer to treatment facilities but who
remain under your jurisdiction
Persons out to court while under your jurisdiction
Persons held for other jurisdictions

EXCLUDE:
X
X
X

Persons housed in facilities operated by two or more
jurisdictions or those held in privately operated jails
Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
All persons in nonresidential community-based
programs run by your jails (e.g., electronic
monitoring, house arrest, community service, day
reporting, work programs)

When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.
Inmates on
December 31,
2012

Males:

Estimate

Females:

Estimate

2. How many males and females under the supervision of
your jail jurisdiction were admitted to your jail facilities
during 2012?
INCLUDE:




New admissions only (i.e., persons officially booked
into and housed in your facilities by formal legal
document and by the authority of the courts or some
other official agency)
Repeat offenders booked on new charges

EXCLUDE:
X

Returns from escape, work release, medical
appointments/treatment facilities, bail, and court
appearances

When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.
New ANNUAL
admissions
during 2012

3. On December 31, 2012, how many persons were confined
in your jail facilities on behalf of any of the following:

Males:

Estimate

Females:

Estimate

a.

U.S. Immigration and
Customs Enforcement:

Estimate

b.

U.S. Marshals Service:

Estimate

c.

All other holds (state and
federal prison, Bureau of
Indian Affairs, or any holds
for other jail jurisdictions):

Estimate

4. Between January 1, 2012, and December 31, 2012, what
was the average daily population of all jail confinement
facilities operated by your jurisdiction?
To calculate the average daily population, add the number of
persons for each day during the period January 1, 2012,
through December 31, 2012, and divide the result by 365.
If daily counts are not available, estimate the average daily
population by adding the number of persons held on the same
day of each month and divide the result by 12.
If average daily population cannot be calculated as directed
above, then estimate the typical number of persons held in
your jail confinement facilities each day.
When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.
Average daily
population
during 2012

Males:

Estimate

Females:

Estimate

5. Between January 1, 2012, and December 31, 2012, how
many persons died while under the supervision of your
jail jurisdiction?
INCLUDE:
 Deaths of ALL persons CONFINED in your jail
facilities; or UNDER YOUR JURISDICTION but out to
court or in special facilities (e.g., hospitals, halfway
houses, work farms, and medical/treatment/ release
centers); or WHILE IN TRANSIT to or from your
facilities while under your jurisdiction.
Number of
inmate deaths
during 2012

Males:
Females:

NOTE: BEFORE COMPLETING THIS FORM, PLEASE BE
SURE THAT THERE ARE ENTRIES FOR ALL RESPONSE
BOXES. FOR EXAMPLE, IF YOU HAVE ZERO FEMALE
DEATHS IN QUESTION 5, PLEASE ENTER 0 IN THE BOX
RATHER THAN LEAVING IT BLANK.
«AGENCY ID»

OMB No. 1121-0249 Approval Expires MO/DAY/YEAR

DEATHS IN CUSTODY—2012
ANNUAL SUMMARY ON INMATES IN
PRIVATE AND MULTI-JURISDICTION JAILS

Form CJ-10A

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
IF YOUR JURISDICTION DID NOT HAVE A DEATH IN CALENDAR YEAR 2012:


Complete this form and return it to RTI International. Once you complete EVERY question, your submission will be
complete for 2012.

IF YOUR JURISDICTION DID HAVE ONE OR MORE DEATHS IN CALENDAR YEAR 2012:



Please ensure that you have completed a 2012 CJ-10 (individual death report) form for each death reported.
If you need additional CJ-10 forms, please go to the DCRP Web site (https://bjsdcrp.rti.org), call 1-800-344-1387,
or send an e-mail to [email protected].

General Information
Please submit your completed form within 30 days of receipt. You may submit your annual summary in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
E-MAIL: [email protected]

MAIL: RTI International, Attn: Data Capture
Project Number: 0212335.001.302.200
PO Box 12194
Research Triangle Park, NC 27709-2194

FAX (TOLL-FREE): 1-866-800-9179
If you need assistance, contact Kim Aspinwall of RTI International toll-free at 1-800-344-1387 or [email protected].

What facilities are included in this data collection?
INCLUDE…
 All confinement facilities, including detention centers, jails, and
other correctional facilities, intended for adults but sometimes
holding juveniles which are either privately owned and operated
or administered by two or more governments (or a board
composed of representatives from two or more governments)
 All jails and city/county correctional centers that hold inmates
beyond arraignment. Report data on all inmates, including
those held in separate holding or lockup areas within your
facility

EXCLUDE…
 Facilities that are exclusively used as temporary holding or
lockup facilities, where inmates are generally held for less
than 72 hours and not held beyond arraignment. If your facility
holds inmates beyond arraignment, report data on ALL
inmates, including those held in separate holding or lockup
areas within your facility
 Deaths of persons in the process of arrest by your agency if
they have not yet been booked into your jail facility. Arrestrelated deaths should be reported using a CJ-11A form

 Special jail facilities (e.g., medical/treatment/release centers,
halfway houses, and work farms)
 Inmates held for jurisdictions other than the participating
jurisdictions
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.

«AGENCY ID»

INMATE COUNTS AND DEATHS

1. How many males and females under the supervision of
your jail facility were confined in your jail facility on
December 31, 2012?
INCLUDE:




Persons on transfer to treatment facilities but who
remain under your jurisdiction
Persons out to court while under your jurisdiction
Persons held for other jurisdictions

3. On December 31, 2012, how many persons were confined
in your jail facilities on behalf of any of the following:
When exact numeric answers are not available, provide
estimates and mark () in the box beside each figure.
a.

U.S. Immigration and
Customs Enforcement:

Estimate

b.

U.S. Marshals Service:

Estimate

c.

All other holds (state and
federal prison, Bureau of
Indian Affairs, or any holds
for other jail jurisdictions):

Estimate

EXCLUDE:
X

Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions

When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.
Inmates on
December 31,
2012

Males:

Estimate

Females:

Estimate

4. Between January 1, 2012, and December 31, 2012, what
was the average daily population of all jail confinement
facilities operated by your jail?
To calculate the average daily population, add the number of
persons for each day during the period January 1, 2012,
through December 31, 2012, and divide the result by 365.

2. How many males and females under the supervision of
your jail facility were admitted to your jail facilities during
2012?
INCLUDE:




New admissions only (i.e., persons officially booked
into and housed in your facilities by formal legal
document and by the authority of the courts or some
other official agency)
Repeat offenders booked on new charges

EXCLUDE:
X

Returns from escape, work release, medical
appointments/treatment facilities, bail, and court
appearances

When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.

New ANNUAL
admissions
during 2012

Males:

Estimate

Females:

Estimate

If daily counts are not available, estimate the average daily
population by adding the number of persons held on the same
day of each month and divide the result by 12.
If average daily population cannot be calculated as directed
above, then estimate the typical number of persons held in
your jail confinement facilities each day.
When exact numeric answers are not available, provide
estimates and mark () the box beside each figure.
Average daily
population
during 2012

Males:

Estimate

Females:

Estimate

5. Between January 1, 2012, and December 31, 2012, how
many persons died while under the supervision of your
jail?
INCLUDE:
 Deaths of ALL persons CONFINED in your jail
facilities; or UNDER YOUR JURISDICTION but out to
court or in special facilities (e.g., hospitals, halfway
houses, work farms, and medical/treatment/ release
centers); or WHILE IN TRANSIT to or from your
facilities while under your jurisdiction.
Number of
inmate deaths
during 2012

Males:
Females:

NOTE: BEFORE COMPLETING THIS FORM, PLEASE BE
SURE THAT THERE ARE ENTRIES FOR ALL RESPONSE
BOXES. FOR EXAMPLE, IF YOU HAVE ZERO FEMALE
DEATHS IN QUESTION 5, PLEASE ENTER 0 IN THE BOX
RATHER THAN LEAVING IT BLANK.

«AGENCY ID»

OMB No. 1121-0249 Approval Expires MO/DAY/YEAR

DEATHS IN CUSTODY—2013
DEATH REPORT ON INMATES
UNDER JAIL JURISDICTION

Form CJ-9

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
If no deaths occurred in 2013:

You do not need to report anything at this time.

At the beginning of 2014, you will be asked to complete a summary form whether or not you had a death occurrence in 2013.
If you had more than one death in 2013:

Make copies of this form for each additional death.

Complete the entire form for each inmate death.

Once your death records are complete, there are several ways to submit a death report:
ONLINE: Complete the report online at: https://bjsdcrp.rti.org

MAIL: RTI International, Attn: Data Capture
Project Number: 0212335.001.302.200
PO Box 12194
Research Triangle Park, NC 27709-2194

E-MAIL: [email protected]
FAX (TOLL-FREE): 1-866-800-9179

If you need assistance, contact Kim Aspinwall of RTI International toll-free at 1-800-344-1387 or [email protected]

What deaths should be reported?
INCLUDE deaths of ALL persons…

EXCLUDE deaths of ALL persons…



Confined in your jail facilities, whether housed under
your own or another jurisdiction



Confined in facilities operated by two or more
jurisdictions or those held in privately operated jails



Under your jurisdiction but housed in special jail
facilities (e.g., medical/treatment/release centers,
halfway houses, and workfarms); or on transfer to
treatment facilities



Under your jurisdiction but in nonresidential communitybased programs run by your jails (e.g., electronic
monitoring, house arrest, community service, day
reporting, work programs)



Under your jurisdiction but out to court





Under your jurisdiction but AWOL, escaped, or on longterm transfer to another jurisdiction

In transit to or from your facilities while under your
jurisdiction



In the process of arrest by your agency, but not yet
booked into your jail facility

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.

form to this address.
«AGENCY ID»

LOCAL JAIL INMATE DEATH REPORT

1. What was the inmate’s name?
LAST

8. On what date was the inmate admitted to a facility
under your jurisdiction?

FIRST

MI
MONTH

DAY

YEAR

2. On what date did the inmate die?
2
MONTH

DAY

0

1

9. Was the inmate being confined in your jail facility
on behalf of any of the following?

3

YEAR

PLEASE PROVIDE A RESPONSE FOR EACH ITEM (a–c)

3. What was the name and location of the correctional
facility involved?
Facility Name:

Facility City:

Facility State:

DON’T
YES NO KNOW
a. U.S. Immigration and
Customs Enforcement................................ ...........
b. U.S. Marshals Service ................................ ...........
c. State or federal prison,
Bureau of Indian Affairs,
or any other jail jurisdiction......................... ...........

10. For what offense(s) was the inmate being held?
4. What was the inmate’s date of birth?

a.
b.

MONTH

DAY

YEAR

c.
5. What was the inmate’s sex?
Male
Female

6. Was the inmate of Hispanic, Latino, or Spanish
origin?
Yes
No
7. In addition, what was the inmate’s race? Please
select one or more of the following racial
categories:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Some other race

d.
e.

11. What was the inmate’s legal status at time of
death? (For inmates with more than one status, report
the status associated with the most serious offense.)
Convicted—new court commitment
Convicted—returned probation/parole violator
Unconvicted
Other
Please Specify:

12. Since admission, did the inmate ever stay
overnight in a mental health observation unit or an
outside mental health facility?
Yes
No
Don’t Know

«AGENCY ID»

13. Where did the inmate die?
In a general housing unit within the jail facility or on jail grounds
In a segregation unit
In a special medical unit/infirmary within jail facility
In a special mental health services unit within jail facility
In a medical center outside jail facility
In a mental health center outside jail facility
While in transit
Elsewhere
Please Specify:

14. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, postmortem exam, or
review of medical records) available to establish an official cause of death?
YES
CONTINUE TO Q15
Evaluation complete—results are pending
SKIP REMAINING QUESTIONS AND SUBMIT THIS FORM—YOU WILL BE CONTACTED AT A LATER
TIME FOR THE CAUSE OF DEATH
No evaluation is planned
15. What was the cause of death?

CONTINUE TO Q15
*** Please SPECIFY cause of death—it is critical information ***

Illness—Exclude AIDS-related deaths [Specify]
Acquired Immune Deficiency Syndrome (AIDS)
Accidental alcohol/drug intoxication [Describe]
Accidental injury to self [Describe]
Accidental injury by other (e.g., vehicular
accidents during transport) [Describe]
Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) [Describe]
Homicide [Describe]
Other cause(s) [Specify]

16. Where did the incident (e.g., accident, suicide, or homicide) causing the death take place?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
In the jail facility or on the jail grounds
In the inmate’s cell/room
In a temporary holding area/lockup
In a common area within the facility (e.g., yard, library, cafeteria)
[PLEASE
In a segregation unit
SPECIFY]
In a special medical unit/infirmary
In a special mental health services unit
Elsewhere within the jail facility
Please Specify:

Outside the jail facility (e.g., while on work release or on work detail)
Elsewhere
Please Specify:
«AGENCY ID»

17. When did the incident (e.g., accident, suicide, or homicide) causing the death occur?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
Morning (6 am to Noon)
Afternoon (Noon to 6 pm)
Evening (6 pm to Midnight)
Overnight (Midnight to 6 am)
18. Excluding emergency care provided at the time of death, did the inmate receive any of the following medical
services for the medical condition that caused his/her death after admission to your correctional facilities?
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide

a.
b.
c.
d.
e.
f.

YES
NO
DON’T KNOW
Evaluation by physician/medical staff ......................................................
PLEASE PROVIDE A
Diagnostic tests (e.g., X-rays, MRI) .........................................................
RESPONSE FOR
Medications ...............................................................................................
EACH ITEM (a–f)
Treatment/care other than medications ....................................................
Surgery ......................................................................................................
Confinement in special medical unit. ........................................................

19. Was the cause of death the result of a pre-existing medical condition or did the inmate develop the condition
after admission? (If multiple conditions caused the death and any of the conditions were pre-existing, mark
―Pre-existing medical condition.‖)
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide
Pre-existing medical condition
Deceased developed condition after admission
Could not be determined
Please add any additional notes regarding this death here:

«AGENCY ID»

OMB No. 1121-0249 Approval Expires MO/DAY/YEAR

DEATHS IN CUSTODY—2013
DEATH REPORT ON INMATES IN
PRIVATE AND MULTI-JURISDICTIONAL JAILS

Form CJ-10

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
If no deaths occurred in 2013:

You do not need to report anything at this time.

At the beginning of 2014, you will be asked to complete a summary form whether or not you had a death occurrence in 2013.
If you had more than one death in 2013:

Make copies of this form for each additional death.

Complete the entire form for each inmate death.

Once your death records are complete, there are several ways to submit a death report:
ONLINE: Complete the report online at: https://bjsdcrp.rti.org

MAIL: RTI International, Attn: Data Capture
Project Number: 0212335.001.302.200
PO Box 12194
Research Triangle Park, NC 27709-2194

E-MAIL: [email protected]
FAX (TOLL-FREE): 1-866-800-9179

If you need assistance, contact Kim Aspinwall of RTI International toll-free at 1-800-344-1387 or [email protected]

What deaths should be reported?
INCLUDE deaths of ALL persons…


Confined in your jail facilities, even if housed for
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



In transit to or from your facilities while under your
supervision

EXCLUDE deaths of ALL persons…


Under your jurisdiction but in nonresidential communitybased programs run by your jails (e.g., electronic
monitoring, house arrest, community service, day
reporting, work programs)



Under your jurisdiction but AWOL, escaped, or on longterm transfer to another jurisdiction



In the process of arrest by your agency, but not yet
booked into your jail facility

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.

form to this address.
«AGENCY ID»

JAIL INMATE DEATH REPORT
1. What was the inmate’s name?
LAST

8. On what date was the inmate admitted to your jail
facility?

FIRST

MI
MONTH

DAY

YEAR

2. On what date did the inmate die?
2

2
MONTH

DAY

0

0

1

1

3

9. Was the inmate being confined in your jail facility
on behalf of any of the following?

3

YEAR

PLEASE PROVIDE A RESPONSE FOR EACH ITEM (a–c)

3. What was the name and location of the correctional
facility involved?
FacilityName:
Name:
Facility
Facility Location:
Facility City:

Facility State:

DON’T
YES NO KNOW
a. U.S. Immigration and
Customs Enforcement ................................ ..........
b. U.S. Marshals Service ................................ ..........
c. State or federal prison,
Bureau of Indian Affairs,
or any other jail jurisdiction ......................... ..........

10. For what offense(s) was the inmate being held?
4. What was the inmate’s date of birth?
MONTH

DAY

YEAR

a.
b.
c.

5. What was the inmate’s sex?
Male
Female

d.
e.

6. Was the inmate of Hispanic, Latino, or Spanish
origin?
Yes
No

7. In addition, what was the inmate’s race? Please
select one or more of the following racial
categories:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Some other race

11. What was the inmate’s legal status at time of
death? (For inmates with more than one status, report
the status associated with the most serious offense.)
Convicted—new court commitment
Convicted—returned probation/parole violator
Unconvicted
Other
Please Specify:

12. Since admission, did the inmate ever stay
overnight in a mental health observation unit or an
outside mental health facility?
Yes
No
Don’t Know

«AGENCY ID»

13. Where did the inmate die?
In a general housing unit within the jail facility or on jail grounds
In a segregation unit
In a special medical unit/infirmary within jail facility
In a special mental health services unit within jail facility
In a medical center outside jail facility
In a mental health center outside jail facility
While in transit
Elsewhere
Please Specify:

14. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, postmortem exam, or
review of medical records) available to establish an official cause of death?
YES
CONTINUE TO Q15
Evaluation complete—results are pending
SKIP REMAINING QUESTIONS AND SUBMIT THIS FORM - YOU WILL BE CONTACTED AT A LATER
TIME FOR THE CAUSE OF DEATH
No evaluation is planned
CONTINUE TO Q15

15. What was the cause of death?

*** Please SPECIFY cause of death—it is critical information ***

Illness—Exclude AIDS-related deaths [Specify]
Acquired Immune Deficiency Syndrome (AIDS)
Accidental alcohol/drug intoxication [Describe]
Accidental injury to self [Describe]
Accidental injury by other (e.g., vehicular
accidents during transport) [Describe]
Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) [Describe]
Homicide [Describe]
Other cause(s) [Specify]
16. Where did the incident (e.g., accident, suicide, or homicide) causing the death take place?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
In the jail facility or on the jail grounds
In the inmate’s cell/room
In a temporary holding area/lockup
In a common area within the facility (e.g., yard, library, cafeteria)
[PLEASE
In a segregation unit
SPECIFY]
In a special medical unit/infirmary
In a special mental health services unit
Elsewhere within the jail facility
Please Specify:

Outside the jail facility (e.g., while on work release or on work detail)
Elsewhere
Please Specify:

«AGENCY ID»

17. When did the incident (e.g., accident, suicide, or homicide) causing the death occur?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
Morning (6 am to Noon)
Afternoon (Noon to 6 pm)
Evening (6 pm to Midnight)
Overnight (Midnight to 6 am)
18. Excluding emergency care provided at the time of death, did the inmate receive any of the following medical
services for the medical condition that caused his/her death after admission to your correctional facilities?
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide

a.
b.
c.
d.
e.
f.

YES
NO
DON’T KNOW
Evaluation by physician/medical staff ......................................................
PLEASE PROVIDE A
Diagnostic tests (e.g., X-rays, MRI) .........................................................
RESPONSE FOR EACH
Medications ...............................................................................................
ITEM (a–f)
Treatment/care other than medications ....................................................
Surgery ......................................................................................................
Confinement in special medical unit. ........................................................

19. Was the cause of death the result of a pre-existing medical condition or did the inmate develop the condition
after admission? (If multiple conditions caused the death and any of the conditions were pre-existing, mark
―Pre-existing medical condition.‖)
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide
Pre-existing medical condition
Deceased developed condition after admission
Could not be determined
Please add any additional notes regarding this death here:

«AGENCY ID»