Form NPS-4 Quarterly Summary of Inmate Deaths in State Prision

OMB No. 1121-0249 Approval Expires 12/31/2012

NPS-4

U.S. DEPARTMENT OF JUSTICE

DEATHS IN CUSTODY — 2009

FORM
(10-5-2009)

BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

QUARTERLY SUMMARY OF INMATE DEATHS
IN STATE PRISONS

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

City
FAX
NUMBER

Number

State
Area Code

ZIP Code

Number

E-MAIL
ADDRESS

Reporting Period (Mark only one.)
State

‰ 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

During the reporting quarter marked above, how
many persons died while in the custody of your
State correctional facilities?

What deaths should be reported?
• INCLUDE deaths of ALL persons —
CONFINED in your correctional facilities, whether
housed under your jurisdiction or that of another State;
UNDER YOUR JURISDICTION but housed in private
correctional facilities, whether located in or out of State;

Number of deaths

UNDER YOUR JURISDICTION but in special facilities
(e.g., hospitals, medical/treatment/release centers,
halfway houses, police/court lockups, and work farms); or
WHILE IN TRANSIT to or from your facilities while
under your supervision.

• EXCLUDE deaths of ALL persons —
DEATHS BY EXECUTION that were carried out in your State.
CONFINED in local jail facilities, whether located in or out of State.
UNDER YOUR JURISDICTION but housed in a State-operated
correctional facility in another State or in a Federal facility.
UNDER PROBATION OR PAROLE SUPERVISION in your State.

Instructions:
• For each inmate death reported, complete a
STATE PRISON INMATE DEATH REPORT
(NPS-4A). Please complete items 1 through
16 for each inmate death.
• IF NO DEATHS OCCURRED, report "0" in the
space provided above.
• If you need assistance, call Chris Ellis of RTI International toll-free at 1-800-###-####,
or e-mail [email protected].
• Please submit your data within 60 days of the end
of each quarter.
• You may complete this survey online at:
http://www.rti.com/deaths/
• If you prefer, you may also return these by fax or
parcel delivery.
FAX (TOLL FREE): 1–888–###–####
PARCEL DELIVERY ADDRESS: 3040 Cornwallis
Road, P.O. Box 12194, Research Triangle Park, NC
27709-2194

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, NW,
Washington, DC 20531.