Information Collection

Deaths in Custody Reporting Program

IC 204168 under ICR 201209-1121-005 · OMB 1121-0249.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0249 can be found here:

Documents and Forms

Document Name Document Type
Form NPS-4; NPS-4A Deaths in Custody Reporting Program Form and Instruction
NPS-4; NPS-4A Deaths in Custody, 2012 Annual Summary of Inmate Deaths DCRP-prisons 2012 ASF form and 2013 death form.pdf Form and Instruction
CJ-9A; CJ-10A; CJ- 2012 Annual Sum. on Inmates - Jail Juris.; 2012 Annual S DCRP-jails 2012 ASF form and 2013 death incident form.pdf Form and Instruction
CJ-11; CJ-11A Arrest-Related Deaths Summary of Incidents, 2013; Arrest DCRP-ARD 2013 summary and death forms.pdf Form and Instruction
Appendix C Attachments A-J.pdf Appendix C - All Attachments IC Document
DCRP Web Form Screen Shots.docx Draft Screen Shots for Prisons and Jails Web Form IC Document
jail letter with confidentiality assurances_OMB 2012.doc Example of Cover Letter with Confidentiality Assurance IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Deaths in Custody Reporting Program	Agency IC Tracking Number:	BJS

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NPS-4; NPS-4A	Deaths in Custody, 2012 Annual Summary of Inmate Deaths in State Prisons and 2013 State Prison Inmate Death Report	DCRP-prisons 2012 ASF form and 2013 death form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CJ-9A; CJ-10A; CJ-9; CJ-10	2012 Annual Sum. on Inmates - Jail Juris.; 2012 Annual Sum. of Inmates in Private & Multi Jails; 2012 Death Report -Jail Jurisdiction; 2013 Death Report on Inmates in Private & Multijurisdiction Jail	DCRP-jails 2012 ASF form and 2013 death incident form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CJ-11; CJ-11A	Arrest-Related Deaths Summary of Incidents, 2013; Arrest-Related Deaths Incident Report, 2013; and Question by Question Guide for CJ-11A	DCRP-ARD 2013 summary and death forms.pdf	Yes	Yes	Fillable Fileable

Line of Business: Correctional Activities

Subfunction: Criminal Incarceration

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,308	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	11,308	-8,000	19,308
Annual IC Time Burden (Hours)	4,129	-505	4,634
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix C - All Attachments	Appendix C Attachments A-J.pdf	09/21/2012
Draft Screen Shots for Prisons and Jails Web Form	DCRP Web Form Screen Shots.docx	09/21/2012
Example of Cover Letter with Confidentiality Assurance	jail letter with confidentiality assurances_OMB 2012.doc	12/18/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.