Information Collection

Deaths in Custody Reporting Program

IC 204168 under ICR 201308-1121-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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 2013 Annual Summary on Inmates Under Jail Jurisdiction Appendix_C_2013 CJ-9A_10A.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

IC Title:

Deaths in Custody Reporting Program

Agency IC Tracking Number:

BJS

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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	2013 Annual Summary on Inmates Under Jail Jurisdiction	Appendix_C_2013 CJ-9A_10A.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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	11,308	0	11,308
Annual IC Time Burden (Hours)	7,726	3,597	4,129
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.