CJ-11A Arrested Related Death Report

CJ-11A Addendum

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

Return to: State reporting coordinator
(See form CJ-11 for a national listing, or call the Bureau of
Justice Statistics at 202.307.0765.)

Form CJ-11A

Arrest-related Death report

2010

State
Reporting period (Mark only one)
 Quarter 1 (January 1–March 31)  Quarter 2 (April 1–June 30) 
Quarter 3 (July 1–September 30)

1. What was the name of the deceased?

Last

First

8. What was the manner of death?
Middle initial

01  Homicide by law enforcement officer(s)
02  Other homicide
03  Suicide
04  Accidental injury to self
05  Accidental injury caused by others
06  Accidental alcohol/drug intoxication

2. What was the time and date of death?

:

 AM  PM

Month

 Quarter 4 (October 1–December 31)

Day

,2010

3. Where did the event causing the death occur?

Specify

Street address

07  Illness—Specify

City, State, Zip

08  Other—Specify

4. What law enforcement agency was involved?

9. What was the cause of death?

Name

ORI#

10. Was the cause of death listed above determined from
information in a death certificate?

5. What was the deceased’s date of birth?
Month

Day

Year

01  Yes
02  No—other—Specify

or Age

6. What was the deceased’s sex?

11. Did the deceased commit or allegedly commit any
criminal offenses in the events leading up to the death?

01  Male
02  Female

01  Yes
02  No—medical/mental health assistance call

7. What was the deceased’s race/ethnic origin?
01  White (not of Hispanic origin)
02  Black, or African American (not of Hispanic origin)
03  Hispanic or Latino
04  American Indian/Alaska Native (not of Hispanic origin)
05  Asian (not of Hispanic origin)
06  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

98  Don’t know

03  No—other—Specify

12. What were the most serious reported offenses
of the deceased?
01
02
03

13. Did the deceased die from a medical condition, injuries
sustained during the arrest process, or alcohol/drug
intoxication?—Mark (x) all that apply
01  Medical condition (e.g., heart attack)
02  Injuries
03  Alcohol/drug intoxication
98  Don’t know

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Name of deceased
14. If the deceased died from arrest-related injuries, how
were these injuries sustained?—Mark (x) all that apply
01  Inflicted by law enforcement officers at crime/arrest scene
02  Inflicted by others at crime/arrest scene
03  Inflicted by law enforcement officers during transit/booking
04  Self-inflicted—Accidental
05  Self-inflicted—Suicide
98  Don’t know
99  Not applicable

15. Were any of the following used by law enforcement
officers during the arrest process?
01  Yes—Mark (x) all that apply
01  Handcuffs
02  Leg shackles
03  Pepper spray, mace
04  Conducted energy device (e.g., taser, stun-gun)
05  Firearm discharge
06  Other device (e.g., tire deflation device)
Specify
02  No
98  Don’t know

16. At any time during the arrest process, did the
deceased—Mark (x) all that apply
01  Appear intoxicated (either alcohol or drugs)?
02  Exhibit any mental health problems?
03  Verbally threaten the officer(s) involved?
04  Resist being handcuffed or arrested?
05  Attempt to escape/flee from custody?
06  Attempt to grab, hit or fight with the officer(s) involved?
97  None of the above
98  Don’t know

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 weapons

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

19. Where did the death occur?
01  At booking center/police lockup—Complete items 20–23
02  At crime/arrest scene
03  At medical facility following clinical intervention
04  Dead on arrival at medical facility
05  En route to booking center/police lockup
06  Elsewhere
Specify location

Complete the rest of this form only if the death occurred at a
booking center.
20. What was the time and date of the deceased’s entry into
the law enforcement facility where the death occurred?

:

01  Handgun
02  Rifle/shotgun
03  Firearm,unspecified
04  Nightstick or baton
05  Conducted energy device
06  Other weapon
Specify
98  Don’t know
99  Not applicable

 AM PM Month

Day

, 2010

21. At the time of entry into the law enforcement facility, did
the deceased—Mark (x) all that apply
01  Appear intoxicated (either alcohol or drugs)?
02  Exhibit any mental health problems?
03  Exhibit any medical problems?
97  None of the above
98  Don’t know

22. If death was an accident or homicide, who caused the
death?
01  Deceased
02  Other detainees
03  Law enforcement/correctional staff
04  Other persons
Specify
98  Don’t know
99  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  Firearm
02  Blunt instrument
03  Knife, cutting instrument
04  Hanging, strangulation
05  Drug overdose
06  Other
Specify
99  Not applicable; cause of death was intoxication or illness

97  None of the above

18. If a weapon caused the death, what types of weapons
were used?—Mark (x) all that apply

Form
complete,
stop here

Notes