Form CJ-15 Juvenile Residential Facilty Census

Juvenile Residential Facilty Census (JRFC)

Attachment C - JRFC Form

Juvenile Residential Facilty Census

OMB: 1121-0219

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1121-0219 can be found here:

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Conducted by
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
FOR
OFFICE OF JUVENILE JUSTICE AND
DELINQUENCY PREVENTION

U.S. DEPARTMENT OF JUSTICE

Juvenile Residential Facility Census
QUESTIONNAIRE FOR

This questionnaire asks about services, staff, and persons assigned
beds in this facility on Wednesday, OCTOBER 22, 2014.

PLEASE COMPLETE AND MAIL THIS FORM IN THE ENCLOSED
ENVELOPE BY NOVEMBER 28, 2014
Return the completed form to:

U.S. Census Bureau
P.O. Box 5000
Jeffersonville, IN 47199-5000
GOVS/JRFC
WEBSITE: https://respond.census.gov/jrfc
Fax: 1–888–262–3974
EMAIL: [email protected]

If you have any questions, call Alonzo Johnson U.S. Census
Bureau, 1–800–352–7229.

PERSON COMPLETING THIS QUESTIONNAIRE

Name

E-mail address

Title
Telephone

Business address – Number and street/or P.O. Box/Route number
Area code

Number

Area code

Number

Extension

Fax Number
City
FORM

CJ-15

State
(6-10-2013)

ZIP Code

OMB No. 1121-0219: Approval Expires X/XX/XXXX

Section 1 – GENERAL FACILITY INFORMATION

IMPORTANT INSTRUCTIONS
IMPORTANT INSTRUCTIONS

Please call 1–800–352–7229 to request an
additional questionnaire for each building
with living/sleeping units associated with this
facility that is not at the site of this facility
building or campus.

Complete this questionnaire for the facility
listed on the cover. If additional
questionnaires are needed for other facilities
for which you report, call 1–800–352–7229 to
request more forms.
A juvenile residential facility is a place
where young persons who have committed
offenses may be housed overnight. A facility
has living/sleeping units, such as wings,
floors, dorms, barracks, or cottages on one
campus or in one building.
Any buildings with living/sleeping units that
are not on the same campus should be
considered separate facilities and should be
recorded on separate questionnaires in this
census.

Is the PREPRINTED facility name and mailing
address on the BACK cover page of this form
correct, or do they need to be corrected?
01

Preprinted facility name and mailing
address on the BACK cover page of this
form are correct
Preprinted facility name or mailing address
need to be corrected – Please make necessary
corrections on the BACK cover page of this
form.

On Wednesday, October 22, 2014, did this
facility house any overflow detention
population? "Overflow detention population" refers
to those young persons who, because of the
unavailability of beds in a detention center, are
placed temporarily in a non-detention facility.
If this is a detention center, mark "No".
01

Yes

IMPORTANT INSTRUCTIONS
The following items ask you to use your records
to provide counts of persons who had assigned
beds in this facility at the end of the day on
Wednesday, October 22, 2014. This date has
been chosen carefully to give a standardized
count of persons in facilities like yours across
the country. You will be asked to classify your
facility population into two age groups:
1. those persons under age 21; and

Which of the following best describes the
physical layout of this facility?
Mark (X) ONE response.
This facility is –
01

a part of one building

all of one building

more than one building at a single site or
on one campus
Other – Specify

2. those persons age 21 and older.
You will then be asked to classify each person
UNDER THE AGE OF 21 into just one of the two
following categories:
1. those here because they have been charged
with or court-adjudicated for an offense. An
offense is any behavior that is illegal in your
state for underage persons alone or for both
underage persons and adults.
2. those here for reasons other than offenses
Detailed descriptions of the above categories are
provided in the questions themselves.
Please use your records for October 25, 2000,
to answer the following questions.

Page 2

Are there any other buildings with
living/sleeping units that are associated with
this facility that are not next to this facility
building or on the same campus?
01

Yes

FORM CJ-15 (6-10-2013)

Section 1 – GENERAL FACILITY INFORMATION – Continued
5a. According to your records, at the end of the
day on October 22, 2014, did ANY persons
have assigned beds in this facility? Include
persons who were temporarily away, but had
assigned beds on October 22. Do NOT include staff.
01

Yes

No ➔

STOP HERE and mail this form
ONLY if there were NO PERSONS IN
YOUR FACILITY OR THE FACILITY
WAS CLOSED (permanently or
temporarily) on this date

b. According to your records, at the end of the day
on October 22, 2014, how many persons had
assigned beds in this facility?

Persons

6. How many of the persons who had assigned
beds at the end of the day on Wednesday,
October 22, 2014 were AGE 21 or older?
Include persons who were temporarily away, but
had assigned beds on October 22.
Do NOT include staff. Please write "0" if there are
NO persons age 21 or older.

Persons 21 or older

7a. At the end of the day on Wednesday,
October 22, 2014, did ANY persons UNDER
AGE 21 have assigned beds in this facility?
INCLUDE juveniles being tried as adults in criminal
court. Do NOT include staff.
01

Yes

No ➔ STOP HERE and mail this form ONLY
IF there were no persons under 21 in
your facility on this date

b. According to your records, at the end of the
day on Wednesday, October 22, 2014, how
many young persons under age 21 had
assigned beds in this facility? Include young
persons who were temporarily away but had
assigned beds on October 22. Do NOT include staff.

8a. At the end of the day on Wednesday,
October 22, 2014, did ANY of the young
persons UNDER AGE 21 have assigned beds in
this facility SPECIFICALLY BECAUSE they
were CHARGED WITH OR
COURT-ADJUDICATED FOR AN OFFENSE? An
offense is any behavior that is illegal in your state
for underage persons alone or for both underage
persons and adults.
INCLUDE in your count persons UNDER AGE 21
here BECAUSE THEY WERE CHARGED WITH OR
ADJUDICATED FOR:

• ANY offense that is illegal for both adults and
underage persons.

• AN offense that is ILLEGAL IN YOUR STATE for
underage persons but not for adults. Examples are
running away, truancy, incorrigibility, curfew
violation, and underage liquor violations. Count
persons with these behaviors here ONLY IF THE
BEHAVIORS ARE ILLEGAL IN YOUR STATE. This
includes those CHINS (Children in Need of
Services) and PINS (Persons in Need of Services)
who are here BECAUSE of an offense.
• ANY offense being adjudicated in juvenile or
criminal court, including a probation or parole
violation.
DO NOT INCLUDE here:
• Young persons under age 21 who have committed
one or more offenses in the past, BUT HAVE
ASSIGNED BEDS ON OCTOBER 22 FOR REASONS
OTHER THAN OFFENSES.
• Young persons under 21 assigned beds here
BECAUSE OF REASONS OTHER THAN
OFFENSES, such as neglect, abuse, dependency,
abandonment, mental health problems, substance
abuse problems. These persons will be counted in
questions 9a and 9b.
• Young persons under 21 who have run away,
been truant or incorrigible, or violated curfew, IF
THESE BEHAVIORS ARE NOT CONSIDERED
ILLEGAL IN YOUR STATE. These young persons
will be counted in questions 9a and 9b.
• Those persons who are PINS (Persons in Need of
Services) or CHINS (Children in Need of Services)
who have assigned beds because of REASONS
OTHER THAN OFFENSES. These young persons
will be counted in questions 9a and 9b.
01

Yes

No ➔

Go to Question 9a on page 4

b. According to your records for the end of the
Young persons under the age of 21

NOTE
As a check, the sum of question 6
(persons 21 and older) and 7b (young
persons under age 21) should equal
the sum reported in question 5b
(number of persons assigned beds in
the facility).

FORM CJ-15 (6-10-2013)

day on Wednesday, October 22, 2014, HOW
MANY YOUNG PERSONS UNDER AGE 21 had
assigned beds in the facility SPECIFICALLY
BECAUSE they were CHARGED WITH OR
COURT-ADJUDICATED FOR AN OFFENSE, as
defined in question 8a?
Include young persons who were temporarily
away but had assigned beds on October 22. Do
NOT include staff.
Young persons under age 21
here because they were charged
with or court-adjudicated for an
offense.
Page 3

Section 1 – GENERAL FACILITY INFORMATION – Continued
9a. At the end of the day on Wednesday,

10a. Does this facility provide ON-SITE

October 22, 2014, did ANY of the young
persons UNDER AGE 21 have assigned beds in
this facility FOR REASONS OTHER THAN
OFFENSES? DO NOT include staff.
INCLUDE here:
• Young persons under age 21 assigned beds here for
NON-OFFENSE REASONS, such as neglect, abuse,
dependency, abandonment, mental health
problems, substance abuse problems, or another
non-offense reason

RESIDENTIAL TREATMENT?
01

Yes

➔

Go to Question 11

b. What kind of treatment is provided INSIDE this
facility? Mark (X) all that apply.

• Young persons under age 21 who have committed
one or more offenses in the past, BUT ARE
ASSIGNED BEDS HERE ON OCTOBER 22 FOR
REASONS OTHER THAN THESE OFFENSES

Mental health treatment

Substance abuse treatment

Sex offender treatment

Treatment for arsonists

Treatment specifically for violent offenders

Other – Specify

• Young persons under age 21 who have run away,
been truant or incorrigible, or violated curfew, IF
THESE BEHAVIORS ARE NOT CONSIDERED
ILLEGAL IN YOUR STATE.
• Young persons assigned beds here due to
voluntary or non-offense related admissions.

11.

Do NOT INCLUDE:
• Young persons assigned beds here BECAUSE
THEY WERE CHARGED WITH OR
COURT-ADJUDICATED FOR AN OFFENSE. These
persons are counted in questions 8a and 8b.
01

Yes

No ➔

Go to NOTE below

12.

Does this facility provide foster care?
01

Yes, for all young persons

Yes, for some but not all young persons

Does this facility provide independent living
arrangements for any young persons?
01

Yes

b. According to your records for the end of the
day on Wednesday, October 22, 2014, HOW
MANY YOUNG PERSONS UNDER AGE 21 had
assigned beds in this facility FOR REASONS
OTHER THAN OFFENSES, AS DEFINED IN 9a?
Include young persons who were temporarily away
but had assigned beds on October 22. Do NOT
include staff.
Young persons under age 21 here
because of non-offense reasons.

NOTE
As a check, the sum of questions 8b
(young persons under 21 with offenses)
and 9b (young persons under 21 with
reasons other than offenses) should equal
7b (the number of young persons under
age 21)

Page 4

FORM CJ-15 (6-10-2013)

Section 1 – GENERAL FACILITY INFORMATION – Continued
13. What type of residential facility is the one listed
on the front cover? Mark (X) those that apply.
01

Detention center: A short-term facility that
provides temporary care in a physically restricting
environment for juveniles in custody pending court
disposition and, often, for juveniles who are
adjudicated delinquent and awaiting disposition or
placement elsewhere, or are awaiting transfer to
another jurisdiction. In some jurisdictions,
detention centers may also hold juveniles
committed for short periods of time as part of their
disposition (e.g., weekend detention).
Training school/Long-term secure facility: A
specialized type of facility that provides strict
confinement and long-term treatment generally for
post-adjudication committed juvenile offenders.
Includes training schools, juvenile correctional
facilities, youth development centers.
Reception or diagnostic center: A short-term
facility that screens juvenile offenders committed
by the courts and assigns them to appropriate
correctional facilities.
Group home/Halfway house: A long-term facility
that is generally non-secure and intended for
post-adjudication commitments in which young
persons are allowed extensive contact with the
community, such as attending school or holding a
job.
Residential treatment center: A facility that
focuses on providing some type of individually
planned treatment program for youth (substance
abuse, sex offender, mental health, etc.) in
conjunction with residential care. Such facilities
generally require specific licensing by the state
that may require that treatment provided is
Medicaid-reimbursable.
Boot camp: A secure facility that operates like
military basic training. It is designed to combine
elements of basic military training programs,
correctional components and treatment programs.
The emphasis is on strict discipline, drills, and
work.
Ranch, forestry camp, wilderness or marine
program or farm: These are long-term generally
non-secure residential facilities often located in a
relatively remote area. The juveniles participate in a
structured program that emphasizes outdoor work,
including conservation and related activities.

14a. Does this facility have one or more
living/sleeping units, such as wings, floors, dorms,
barracks, or cottages, designed to keep any young
persons separate in housing and activities from
other residents for specialized care or security? Do
NOT include time-out rooms, isolation rooms or
infirmaries.
IF THE ONLY REASON for separate housing and
activities ARE SEX OR AGE, ANSWER NO.
01

Yes

➔

Go to NOTE A

b. Do any of these separate living/sleeping units
differ in terms of –
Mark (X) all that apply.
01

average length of stay of young persons

physical security and/or monitoring of young
persons

number of staff per young person

type of treatment program

characteristics of young persons

specialized criteria for staff selection

other? – Specify

c. What is the purpose for having separate
living/sleeping units? Mark (X) all that apply.
01

To provide two or more types of
specialized care in separate living/sleeping
units

To provide a series of separate
living/sleeping units with different
specialized care that all young persons
move through from the time they enter
until the time they leave

To provide two or more levels of security

Some other reason – Specify

d. Do the separate living/sleeping units within
this facility share any of the following –
Mark (X) all that apply.

Runaway and homeless shelter: A short-term
facility that provides temporary care in a physically
unrestricted environment. It can also provide
longer-term care under a juvenile court disposition
order.
Other type of shelter: This includes emergency
non-secure shelters where juveniles are housed
short-term until another placement can be found.

The same agency affiliation

The same mailing address

The same on-site administrators

One or more staff directly caring for the
young persons

One or more security staff

The same school rooms

Other: This includes independent living programs
and anything that cannot be classified above.
Specify

The same dining room at the same time

The same recreational areas at the same time

The same laundry services

None of the above services are shared

FORM CJ-15 (6-10-2013)

Page 5

Section 1 – GENERAL FACILITY INFORMATION – Continued
NOTE
A

19a. Are ANY young persons in this facility locked

Questions 15 and 16 ask who OWNS
this facility. Later you will be asked
who OPERATES this facility.

into their sleeping rooms by staff at ANY time
to confine them?

15a. Is this facility OWNED by one or more of the
following –
Mark (X) all that apply.
01
a private non-profit agency
02

a for profit agency

a government agency

Yes

Mark (X) all that apply.

➔

Go to Question 16

➔

Go to
NOTE B

What is the level of the government agency
that OWNS this facility?
Mark (X) all that apply.

When they are out of control

When they are suicidal

Rarely, no set schedule

During shift changes

Whenever they are in their sleeping rooms

At night

Part of each day

Most of each day
All of each day
Other – Specify

A Native American Tribal Government

Federal

State

County

Municipal (includes Washington, DC)

Other – Specify

20.

Questions 17 and 18 ask who
OPERATES this facility.

Does this facility have any of the following
features intended to confine young persons
within specific areas? Mark (X) all that apply.
01

Doors for secure day rooms that are locked
by staff to confine young persons within
specific areas

Wing, floor, corridor, or other internal
security doors that are locked by staff to
confine young persons within specific areas

Outside doors that are locked by staff to
confine young persons within specific
buildings

External gates in fences or walls WITHOUT
razor wire that are locked by staff to
confine young persons

External gates in fences or walls WITH
razor wire that are locked to confine young
persons

Other – Specify

The facility has none of the above features.

17a. Is this facility OPERATED by one or more of the
following –
Mark (X) all that apply.
01

a private non-profit agency

a for profit agency

a government agency

➔

Go to Question 18

b. What is the name of the private non-profit or
for-profit agency that OPERATES this facility?

➔
18.

Page 6

Go to Question 20

into their sleeping rooms by staff?

for-profit agency that OWNS this facility?

NOTE
B

➔

b. When are young persons in this facility locked

b. What is the name of the private non-profit or

16.

Go to
Question
19a

What is the level of the government agency
that OPERATES this facility (either directly or
under a contract with)?
Mark (X) all that apply.
01

A Native American Tribal Government

Federal

State

County

Municipal (includes Washington, DC)

Other – Specify

21a. Are outside doors to any buildings with
living/sleeping units in this facility ever locked?
01

Yes

➔

Go to Question 22

FORM CJ-15 (6-10-2013)

Section 1 – GENERAL FACILITY INFORMATION – Continued
21b. Why are outside doors to buildings with

24.

living/sleeping units in this facility locked?

On the night of Wednesday, October 22, 2014,
what were the sleeping room arrangements for
young persons assigned beds in this facility in
terms of the number of ACTUAL OCCUPANTS
per sleeping room? Answer in terms of the actual
occupancy status on October 22, 2014, regardless of
whether it reflects the occupancy for which the
sleeping room(s) was/were originally designed, and
whether or not young persons slept on makeshift
beds within these sleeping rooms.

Mark (X) all that apply.

living/sleeping units in this facility locked?
Mark (X) all that apply.
01

To keep intruders out

To keep young persons inside this facility

c. WHEN are outside doors to buildings with

22.

Rarely, no set schedule

At night

Part of each day

Most of each day

All of each day

06
07

1 young person per sleeping room (single
occupancy)

2 young persons per sleeping room (double
occupancy)

3 young persons per sleeping room (triple
occupancy)

When the facility is unoccupied

4 young persons per sleeping room

Other – Specify

Between 5 and 10 young persons per sleeping
room

Between 11 and 25 young persons per
sleeping room

More than 25 young persons per sleeping
room

What was the TOTAL NUMBER OF STANDARD
BEDS for young persons in this facility on the
night of Wednesday, October 22, 2014?
Do NOT include staff beds.
• A single bed is one standard bed
• A double bunked bed is two standard beds

Total number of standard beds

25.

Are young persons assigned beds in this
facility given opportunities for VOLUNTARY
participation in large muscle activity at a
location either INSIDE or OUTSIDE of this
facility? Large muscle activity includes such
exercises as group sports, running, aerobics, and
weight training.
01

Yes

23a. On the night of Wednesday, October 22, 2014,
were there ANY OCCUPIED MAKESHIFT BEDS
in this facility?
Makeshift beds are:
• Roll-out mats
• Fold-out cots
• Roll-away beds
• Pull-out mattresses
• Sofas
• Any other beds that are put away or
moved during non-sleeping hours
01

Yes

➔

26a. Are young persons assigned beds in this
facility REQUIRED to participate in large
muscle activity at a location either INSIDE or
OUTSIDE of this facility? Large muscle activity
includes such exercises as group sports, running,
aerobics, and weight training.
01

Yes

➔

Go to Section 2 on page 8

b. How many MINUTES per day are young
Go to Question 24

persons REQUIRED to participate in large
muscle activity at a location either INSIDE
or OUTSIDE this facility?

b. How many makeshift beds were occupied
that night?
Minutes per DAY
Occupied makeshift beds

c. How many DAYS per week are young
persons REQUIRED to participate in large
muscle activity at a location either INSIDE
or OUTSIDE this facility?

Days per WEEK
FORM CJ-15 (6-10-2013)

Page 7

Section 2 – MENTAL HEALTH SERVICES
1a.

After arrival in this facility, are ANY young
persons asked questions or administered a
form which asks questions to determine risk
for suicide?

When are young persons FIRST asked
questions or administered a form which asks
questions to determine risk of suicide?
Mark (X) all that apply.

Yes

➔

Go to Question 6 on page 9

What best describes the process through
which young persons are asked questions or
administered a form which asks questions to
determine risk of suicide?

03
04

Within less than 24 hours after arrival
Between 24 hours and less than 7 days after
arrival
Seven or more days after arrival
Other – Specify

Mark (X) all that apply.
01

02
03

04
05
06
07

One or more questions about suicide
incorporated into the medical history or
intake process
A form or questions designed by this
facility to assess suicide risk
A form or questions designed by a county
or state juvenile justice system to assess
suicide risk
MAYSI- Full Form
MAYSI- Suicide/depression module
V-DISC
Other – Specify

Which young persons are asked questions or
administered a form which asks questions to
determine risk of suicide?
Mark (X) all that apply.
01

ALL young persons are asked questions or
administered a form which asks questions to
determine suicide risk ➔ Go to Question 5a

Young persons who come directly from
home, rather than from another facility
Young persons who display or
communicate suicide risk
Young persons known to have prior suicide
attempts
Young persons for whom no mental health
care record is available
Other young persons not listed above –
Specify

03
04
05

IMPORTANT NOTE
"Mental health professionals" are limited in this
census to – psychiatrists, psychologists with at
least a Master’s degree in PSYCHOLOGY, and
social workers with at least a Master’s in SOCIAL
WORK (MSW, LCSW).
"Counselors" in this census are persons with a
Master’s degree in a field other than psychology
or social work, or persons whose highest degree
is a Bachelor’s in any field.

5a.

Are ANY young persons re-asked questions or
re-administered a form which asks questions
to determine risk for suicide?
01
02

Who asks questions or administers a form
which asks questions to determine risk of
suicide?
Mark (X) all that apply.
01

Counselors/intake workers who have NOT been
trained by mental health professionals

Counselors/intake workers who have been
trained by mental health professionals
A mental health professional, as defined in the
box above

03
04

Some other person – Specify

Go to Question 6 on page 9

Which best describes the conditions under
which young persons are re-asked questions
or re-administered a form that asks questions
to determine suicide risk?
Mark (X) all that apply.
01

02
03

Page 8

Yes
No ➔

No young persons are re-asked questions
or re-administered a form which asks
questions to determine suicide risk
As necessary on a case-by-case basis
Systematically, based on length of stay, facility
events, or negative life events (for example, after
each court appearance, every time the young
person re-enters the facility, after a death in the
family)
Other – Specify

FORM CJ-15 (6-10-2013)

Section 2 – MENTAL HEALTH SERVICES – Continued
6.

Does this facility assign different levels of risk
to young persons based on their perceived risk
of suicide?
01

Yes

NOTE
D

7a.

Yes
No ➔

Do young persons assigned beds receive
mental health services other than a suicide
evaluation either INSIDE or OUTSIDE this
facility?
Mental health services include:
• evaluations and appraisals conducted by
mental health professionals to diagnose or
to identify mental health needs
• ongoing mental health therapy
• ongoing counseling

Are young persons who are determined to be
at risk for suicide ever placed in a sleeping
room or observation room that is locked or
under staff security?
01

The following questions ask about
preventative measures taken once a young
person is identified to be at risk for suicide.
Please include all levels of suicide risk used
by this facility, if any, when answering
these questions.

NOTE
E

Go to Question 8

Which of the following best describes what
happens in the sleeping room or observation
room that is locked or under staff security?

03
04

Mark (X) all that apply.

Camera observation

15 minute staff checks

5 minute staff checks

Line of site supervision (direct or through glass)

Staff assigned to doorway or in sleeping
room/One-on-one supervision/Arms
length supervision

Other – Specify

10a.

No preventative measures are taken when a
young person is determined to be at risk for
suicide

One-on-one supervision/Arms length
supervision

Yes, provided both INSIDE and OUTSIDE
this facility
Yes, provided INSIDE this facility
Yes, provided OUTSIDE this facility
No, this facility does not provide mental
health services ➔ Go to Question 16a on page 11

Is ongoing COUNSELING provided for these
mental health problems provided INSIDE or
OUTSIDE this facility by a COUNSELOR?
Counselors are limited to:
• persons with a Master’s degree in a field
other than psychology or social work
• persons whose highest degree is a
Bachelor’s in any field.

Are any of the following preventative
measures taken when a young person is
determined to be at risk for suicide?
Mark (X) all that apply.

Questions 9 through 18 ask about mental
health services provided at a location either
INSIDE or OUTSIDE this facility. INSIDE
refers to any location on the facility
grounds. OUTSIDE refers to any location
in the community or off facility grounds.

Yes, INSIDE and OUTSIDE this facility

Yes, INSIDE this facility

Yes, OUTSIDE this facility

No, ongoing counseling is
not provided ➔ Go to Question 11 on page 10

Which forms of ongoing COUNSELING for
mental health problems are provided by a
COUNSELOR?
Mark (X) all that apply.
01

Individual counseling

Line-of-sight supervision

Group counseling

Special clothing to identify young persons as at
risk for suicide

Family counseling

Other – Specify

Special clothing designed to prevent suicide
attempts

Restraints used to prevent suicide attempts

Removal of personal items that may be used to
attempt suicide

Removal from the general population

Other – Specify

FORM CJ-15 (6-10-2013)

Page 9

Section 2 – MENTAL HEALTH SERVICES – Continued
11.

Are ANY young persons evaluated or appraised
by a MENTAL HEALTH PROFESSIONAL at a
location INSIDE or OUTSIDE this facility?

14a. Is ongoing THERAPY for mental health
problems provided to young persons by a
MENTAL HEALTH PROFESSIONAL INSIDE or
OUTSIDE this facility?

Evaluations and appraisals are conducted by
mental health professionals to diagnose or to
identify mental health needs.

Mental health professionals are limited to:
• psychiatrists
• psychologists with at least a Master’s
degree in PSYCHOLOGY
• social workers with at least a Master’s
degree in SOCIAL WORK (MSW, LCSW)

01
02

Yes, INSIDE and OUTSIDE this facility
Yes, INSIDE this facility
Yes, OUTSIDE this facility

01
02

12.

➔

03
04

Go to Question 14a

b. Which forms of ongoing THERAPY for mental
health problems are provided by MENTAL
HEALTH PROFESSIONALS?

When are young persons evaluated or
appraised by a MENTAL HEALTH
PROFESSIONAL?

Mark (X) all that apply.

Individual therapy

Within less than 24 hours

Group therapy

Between 24 hours and less than 7 days
after arrival

Family therapy

Seven or more days after arrival

Other – Specify

c.
13.

Yes, INSIDE and OUTSIDE this facility
Yes, INSIDE this facility
Yes, OUTSIDE this facility
No, ongoing THERAPY is
not provided ➔
Go to Question 15

Which young persons are evaluated or
appraised by a MENTAL HEALTH
PROFESSIONAL?

Which of the following best describes this
facility policy on providing THERAPY by a
MENTAL HEALTH PROFESSIONAL INSIDE or
OUTSIDE this facility?
Mark (X) ONLY ONE response.

Mark (X) all that apply.

All young persons receive some therapy at
some point during their stay

ALL young persons are evaluated or appraised
by a MENTAL HEALTH PROFESSIONAL?

Young persons receive therapy only as
needed on a case-by-case basis

Young persons who come directly from
home, rather than from another facility

Other – Specify

Young persons who are ordered by the
court to get an evaluation

Young persons whom staff identify as
needing an evaluation

Young persons known to have mental
health problems

Young persons for whom no mental health
record is available

Other young persons not listed above –
Specify

Page 10

15.

Do MEDICAL health professionals INSIDE or
OUTSIDE this facility prescribe and/or monitor
psychotropic medication for young persons
assigned beds here?
01

Yes, INSIDE and OUTSIDE this facility

Yes, INSIDE this facility

Yes, OUTSIDE this facility

No, psychotropic medications are not prescribed

FORM CJ-15 (6-10-2013)

Section 2 – MENTAL HEALTH SERVICES – Continued
16a. Are there one or more special living/sleeping
unit(s) in this facility reserved just for young
persons with mental health problems that are
separate from other living/sleeping units?
01
02

18.

Are there one or more special living/sleeping
units reserved just for sex offenders that are
separate from other living/sleeping units?

Yes

No ➔

Go to Question 17a

b. Do any of these special living/sleeping units
reserved just for young persons with mental
health problems differ from the other
living/sleeping units in –
Mark (X) all that apply.

19a. Upon a young person’s departure from this
facility, is information regarding their mental
health status, services and/or needs
communicated to the young persons’ new
placement or residence?

average length of stay?

physical security and/or monitoring of
young persons?

Yes

number of staff per young persons?

No ➔

type of treatment program?

characteristics of young persons?

specialized criteria for staff selection?

specialized curriculum of treatment for the
residents of these units?

Other? – Specify

17a. Is there a specialized SEX OFFENDER

b. For which young persons is this information
shared?
Mark (X) all that apply.

Yes

No ➔

Young persons returning to the community
under juvenile justice supervision through
probation, parole, or aftercare

Young persons returning to the community
(their homes, independent living, foster care,
or another type of guardian’s care) without
further juvenile justice supervision
Young persons being placed in adult criminal
justice facilities (prisons, jails)

Go to Question 18
06

b. Are any of the following provided to young

All young persons that depart from the facility
Young persons being placed in other juvenile
justice facilities, including halfway houses,
shelters or other transition homes

treatment program located inside this
facility?
01

Go to Section 3 on page 12

Young persons going to another living or
placement situation – Please explain

persons charged with or adjudicated for a sex
offense?
Mark (X) all that apply.
01

A curriculum of treatment designed
specifically for sex offenders

Individual therapy/counseling specifically
for sex offenders

Group therapy in which all members of the
group are sex offenders

Family therapy/counseling specifically for
sex offenders

Other – Specify

FORM CJ-15 (6-10-2013)

Page 11

Section 3 – EDUCATIONAL SERVICES
1.

After arrival in this facility, are ANY young
persons evaluated to determine their
educational grade levels and their educational
needs at a location either INSIDE or OUTSIDE
this facility?
01

Yes

No ➔

Go to Question 5

After arrival in this facility, when are young
persons evaluated to determine their
educational grade level?
Mark (X) all that apply.

Within less than 24 hours after arrival

Between 24 hours and less than 7 days
after arrival

Seven or more days after arrival

Other – Specify

Which of the following methods are used to
evaluate young persons to determine their
educational grade levels and their educational
needs?
Mark (X) all that apply.

Review of previous academic records

Interview with an education specialist

Administration of one or more written or
computerized tests

Interview with an intake or admissions
counselor

Interview with guidance counselor

Other – Specify

As part of the DISCHARGE process from this
facility, are ANY young persons evaluated to
determine their educational grade levels and
their educational needs?
01

Yes

No ➔

Go to NOTE F on page 13

Which young persons are evaluated to
determine their educational grade levels and
their educational needs as part of the
DISCHARGE process from this facility?
Mark (X) all that apply.
01

ALL young persons are
evaluated ➔ Go to NOTE F on page 13

Young persons going home or to live on
their own

Young persons who have been at this
facility long enough to demonstrate a
change in academic performance

Young persons who have not yet earned a
high school diploma

Young persons who have not yet earned a
GED

As many young persons as the educational
specialists have time to evaluate

Other – Specify

Which young persons are evaluated to
determine their educational grade levels and
their educational needs?
Mark (X) all that apply.
01

ALL young persons are
evaluated ➔ Go to Question 5

Young persons who come directly from
home, rather than from another facility

Young persons whom the staff identify as
needing an assessment

Young persons for whom no educational
record is available

Young persons with known educational
problems

Other young persons not listed above –
Specify

Page 12

FORM CJ-15 (6-10-2013)

Section 3 – EDUCATIONAL SERVICES – Continued

NOTE
F

7a.

Which of the following educational services
are provided to young persons assigned beds
here at a location either INSIDE or OUTSIDE
this facility?
Mark (X) all that apply.
01

Elementary-level education

Middle school-level education

High school-level education

Do ANY young persons assigned beds here
attend school or receive teacher instruction at
a location either INSIDE or OUTSIDE this
facility?

Special education

GED preparation

GED testing

Mark (X) ONE response.

Yes, provided both INSIDE and OUTSIDE
this facility

Post-high school education or post-high
school correspondence courses

Vocational/technical education

Yes, provided INSIDE this facility

Life skills training

Yes, provided OUTSIDE this facility

Other – Specify

No, educational services are not provided
to young persons while assigned beds
here ➔ Go to Section 4 on page 15

Questions 7 through 9 ask about
educational services provided either
INSIDE and/or OUTSIDE this facility.
INSIDE this facility refers to any location
on the facility grounds. OUTSIDE this
facility refers to any location in the
community or off facility grounds.

Which young persons attend school or receive
teacher instruction?
Mark (X) all that apply
01

ALL young persons are required to
attend school or receive teacher
instruction ➔ Go to Question 8

Those young persons who have not
completed high school or their GED

Those young persons with special needs for
remedial education

Those young persons who have been in the
facility long enough to receive educational
services

Those young persons who are required by the
state to attend school because of their age

Those young persons assigned beds in special
living/sleeping units –Specify unit type

Other young persons not listed above –
Specify

FORM CJ-15 (6-10-2013)

9a.

How many hours per WEEK do young persons
attend school or receive teacher instruction
during the scheduled academic school year at a
location either INSIDE or OUTSIDE this
facility?
INSIDE
OUTSIDE
Instructional
hours per WEEK

b. How many months per YEAR do young persons
assigned beds attend school or receive teacher
instruction at a location either INSIDE or
OUTSIDE this facility?
INSIDE

OUTSIDE

Instructional
months per YEAR

Page 13

Section 3 – EDUCATIONAL SERVICES – Continued
10a. Upon a young person’s departure from this
facility, is information regarding their
educational status, services and/or needs
communicated to the young persons’ new
placement or residence?
01

Yes

No ➔

Go to Section 4 on page 15

b. For which young persons is this information
shared?
Mark (X) all that apply.
01
02

Young persons returning to the community
under juvenile justice supervision through
probation, parole, or aftercare

05
06

Page 14

All young persons that depart from the facility
Young persons being placed in other juvenile
justice facilities, including halfway houses,
shelters or other transition homes

Young persons going to another living or
placement situation – Please explain

FORM CJ-15 (6-10-2013)

Section 4 – SUBSTANCE ABUSE SERVICES
1a.

After arrival in this facility, are ANY young
persons evaluated to determine whether they
have substance abuse problems?
Substance abuse problems include problems with
drugs and/or alcohol.

Yes

No ➔ Go to Question 4a

Which of the following methods are used to
evaluate persons after arrival in this facility to
determine whether they have substance abuse
problems?
Mark (X) all that apply.

3a.

Visual observation

Standardized self-report instruments, such
as the SASSI, JASI, ACDI, ASI

Self-report check list inventory which asks
about substance use and abuse

A staff-administered series of questions
which asks about substance use and abuse

None of these methods are used

Other – Specify

When are young persons FIRST evaluated to
determine whether they have substance abuse
problems?
Mark (X) all that apply.
01

Within less than 24 hours after arrival

Between 24 hours and less than 7 days
after arrival

Seven or more days after arrival

Other – Specify

Are ALL young persons evaluated after arrival
in this facility to determine whether they have
substance abuse problems?
01

Yes ➔ Go to Question 4a

No ➔ Continue with Question 3b

After arrival in this facility, which young
persons are evaluated for substance abuse
problems?
Mark (X) all that apply.

4a.

Young persons charged with or adjudicated
for a drug or alcohol-related offense

Young persons identified by the court or a
probation officer as potentially having
substance abuse problems

Young persons identified by facility staff as
potentially having substance abuse
problems

Other young persons not listed above – Specify

Are ANY young persons required to provide urine FOR DRUG ANALYSIS after arrival IN THIS FACILITY?
01

Yes ➔ Continue with Question 4b

No ➔ Go to NOTE G on page 16

Which statements below describe the circumstances under which young persons are required to
provide urine INSIDE this facility FOR DRUG ANALYSIS? Mark (X) all that apply.

PERSONS PROVIDING
URINE SAMPLE

After initial
arrival in this
facility
(1)

a. Young persons who are
suspected of recent drug or
alcohol use
b. Young persons with substance
abuse problems
c. ALL young persons assigned
beds here
FORM CJ-15 (6-10-2013)

CIRCUMSTANCES OF TESTING
Each time young
When drug use is At the request of
At randomly
persons reenter
or drug
the court or
the facility during scheduled times suspected
is present
probation officer
their stay
(2)

(3)

(4)

(5)

Page 15

Section 4 – SUBSTANCE ABUSE SERVICES – Continued

NOTE
G

Questions 5 through 9 ask about substance
abuse services provided at a location
either INSIDE or OUTSIDE this facility.
INSIDE refers to any location on the
facility grounds. OUTSIDE refers to any
location in the community or off facility
grounds.

Mark (X) all that apply.

IMPORTANT INSTRUCTIONS
Substance abuse services include:
• developing a substance abuse
treatment plan
• assigning a case manager to oversee
substance abuse treatment
• assigning young persons to special
living units just for those with substance
abuse problems
• ongoing substance abuse therapy or
counseling
• substance abuse education
Substance abuse treatment professionals
are limited in this census to:
• CERTIFIED substance abuse or
addictions counselors
• psychiatrists
• psychologists with at least a Master’s
degree in PSYCHOLOGY
• social workers with at least a Master’s
degree in SOCIAL WORK (MSW, LCSW)

8a.

Yes, provided both INSIDE and OUTSIDE this
facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, this facility does not provide
substance abuse services ➔ Go to Section 5
on page 18

Page 16

Substance abuse education

Assignment of a case manager to oversee
substance abuse treatment

Development of a treatment plan to specifically
address substance abuse problems

Special living units in which all young persons
have substance abuse offenses and/or problems

None of these services are offered

Which of the following self-led, self-help
groups are provided INSIDE or OUTSIDE
this facility?
01

Alcoholics Anonymous

Narcotics Anonymous

Other – Specify

Is ongoing COUNSELING for substance abuse
problems provided to young persons INSIDE
or OUTSIDE this facility by a COUNSELOR
who is NOT a substance abuse treatment
professional?
Counselors who are NOT substance
abuse treatment professionals are:
• persons with a Master’s degree in a field
other than psychology or social work
• persons whose highest degree is a
Bachelor’s in any field

Do ANY young persons assigned beds here
receive substance abuse services INSIDE or
OUTSIDE this facility other than urinalysis or a
substance abuse screening?
01

Mark (X) all that apply.

Counselors who are NOT substance abuse
treatment professionals are limited to:
• persons with a Master’s degree in a field
other than psychology or social work
• persons whose highest degree is a
Bachelor’s in any field

Which of the following SUBSTANCE ABUSE
services are provided INSIDE or OUTSIDE this
facility?

Yes, provided both INSIDE and OUTSIDE this
facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, ongoing COUNSELING for
substance abuse problems is not
provided ➔ Go to Question 9a on page 17

Which forms of ongoing COUNSELING for
substance abuse problems are provided
INSIDE or OUTSIDE this facility to young
persons by a COUNSELOR who is NOT a
substance abuse treatment professional?
Mark (X) all that apply.
01

Individual counseling

Group counseling

Family counseling

None of these are provided

FORM CJ-15 (6-10-2013)

Section 4 – SUBSTANCE ABUSE SERVICES – Continued
9a.

Is ongoing THERAPY for substance abuse
problems provided to young persons INSIDE
or OUTSIDE this facility by a SUBSTANCE
ABUSE TREATMENT PROFESSIONAL?
Substance abuse treatment professionals are
limited to:
• CERTIFIED substance abuse/addictions
counselors
• psychiatrists
• psychologists with at least a Master’s
degree in psychology
• social workers with a Master’s degree in
SOCIAL WORK (MSW,LCSW)

Yes, provided both INSIDE and OUTSIDE this
facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, ongoing THERAPY for
substance abuse problems is
not provided ➔ Go to Section 5 on page 18

Which forms of ongoing THERAPY for
substance abuse problems are provided
INSIDE or OUTSIDE this facility to young
persons by a SUBSTANCE ABUSE
TREATMENT PROFESSIONAL?

10a. Upon a young person’s departure from this
facility, is information regarding their
substance abuse status, services and/or needs
communicated to the young persons’ new
placement or residence?
01

Yes

No ➔

Go to Section 5 on page 18

b. For which young persons is this information
shared?
Mark (X) all that apply.
01
02

All young persons that depart from the facility
Young persons being placed in other juvenile
justice facilities, including halfway houses,
shelters or other transition homes

Young persons returning to the community
under juvenile justice supervision through
probation, parole, or aftercare

05
06

Young persons going to another living or
placement situation – Please explain

Mark (X) all that apply.

Individual therapy

Group therapy

Family therapy

None of these are provided

Which of the following best describes this
facility policy on providing ongoing therapy
for substance abuse problems INSIDE or
OUTSIDE this facility to persons by a
SUBSTANCE ABUSE TREATMENT
PROFESSIONAL?
Mark (X) ONLY ONE response.
01

All young persons receive specialized
therapy or counseling for substance abuse
problems

Young persons receive specialized therapy
or counseling for substance abuse
problems only as needed on a case-by-case
basis

Other – Specify

FORM CJ-15 (6-10-2013)

Page 17

Section 5 – THE LAST MONTH
3.
IMPORTANT INSTRUCTIONS
The following items ask you to answer questions
about different events that may have occurred at
this facility over a 30-day period.

Mechanical restraints include handcuffs, leg cuffs,
waist bands, leather straps, restraining chairs,
strait jackets or other mechanical devices

The 30-day REFERENCE PERIOD for this section
covers the time between the beginning of the day,
September 1, 2014 and the end of the day on
September 30, 2014.

During the month of September 2014, were
there ANY UNAUTHORIZED DEPARTURES of
any young persons who were assigned beds at
this facility?
An "unauthorized departure" includes any incident
in which a young person leaves without staff
permission or approval for more than 10 minutes
from:
• The physical security perimeter of the facility
• The mandatory supervision of a staff member
when there is no physical security
• The mandatory supervision of transportation
staff
• Any other approved area
01
02

2a.

Yes
No

During the month of September 2014, were
ANY young persons assigned beds at this
facility transported to a hospital emergency
room by facility staff, transportation staff, or
by an ambulance?
01
02

Yes
No ➔

During the month of September 2014, were
ANY of the young persons assigned beds here
restrained by facility staff with a mechanical
restraint?

If the facility staff ONLY used mechanical
restraints during transportation to and from this
facility answer NO.
01
02

Yes
No

During the month of September 2014, were
ANY of the young persons assigned beds here
locked for more than four hours alone in an
isolation, seclusion, or sleeping room to regain
control of their unruly behavior?
Answer NO if:
• Young persons were locked in their
sleeping rooms as part of the facility
routine
OR
• Young persons were locked in their rooms
ONLY for purposes of quarantine, suicide
watch, facility-wide lockdown, or
self-requested seclusion
01
02

Yes
No

Go to Question 3

For what reason(s) were the young persons
transported to a hospital emergency room
DURING THIS 30 DAY PERIOD in September?
Mark (X) all that apply.
01
02
03

05
06
07
08
09

Page 18

Sports-related injury
Work or chore-related injury
An injury that resulted from interpersonal
conflict between one or more young persons,
not including a sports-related injury
An injury that resulted from interpersonal
conflict between a young person and a
non-resident (including staff, visitors, or
persons from the community).
Illness
Pregnancy complications
Labor and delivery
Suicide attempt
A non-emergency injury or illness that occurred
when no physical health professional was
available at the facility or on call
A non-emergency injury or illness that
occurred when no doctor’s appointment
could be obtained in the community
Other – Specify

FORM CJ-15 (6-10-2013)

Section 5 – THE LAST MONTH – Continued
5a.

During the month of September 2014 were
there any instances in which this facility was
unable to secure PHYSICAL HEALTH CARE (at
locations either inside or outside of this
facility) for any young persons with a physical
health complaint or need for physical health
care (both urgent and non-urgent)?

6a.

During the month of September 2014 were
there any instances in which this facility was
unable to secure MENTAL HEALTH CARE (at
locations either inside or outside of this
facility) for any young persons with a mental
health complaint or need for mental health care
(both urgent and non-urgent)?

Yes

No, this facility does not provide or broker
physical health care services (except through
contacting emergency services like
ambulances) ➔ Go to question 6a

No, this facility does not provide or broker
mental health care services (except through
contacting emergency services like
ambulances) ➔ Go to question 7a on page 20

No, there were no such instances ➔
Go to question 6a

No, there were no such instances ➔
Go to question 7a on page 20

b. What reasons prevented PHYSICAL HEALTH

b. What reasons prevented MENTAL HEALTH

CARE from being secured for young persons in
need?

Mark (X) all that apply.

Long-term shortages of physical health care
staffing at this facility

Long-term shortages of mental health care
staffing at this facility

Short-term, temporary shortages of physical
health care staffing at this facility

Short-term, temporary shortages of mental
health care staffing at this facility

Shortages, temporary interruptions in, or
absence of contracts with physical health care
providers in the community

Shortages, temporary interruptions in, or
absence of contracts with mental health care
providers in the community

Shortages in line staff or other direct care staff
to fill in for staff who accompany young
persons to health care services

Shortages in line staff or other direct care staff
to fill in for staff who accompany young
persons to mental health care services

Shortages in transportation staff or vehicles

Single or multiple instances of facility lock
downs or other security issues that prevented
health care “services as usual” from occurring
for all young persons in the facility or all
young persons in specific units or wings of
this facility

Single or multiple instances of facility lock
downs or other security issues that prevented
mental health care “services as usual” from
occurring for all young persons in the facility
or all young persons in specific units or wings
of this facility

Single or multiple instances of security risks
for individual young persons that prevented
health care “services as usual” from occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Single or multiple instances of security risks
for individual young persons that prevented
mental health care “services as usual” from
occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

FORM CJ-15 (6-10-2013)

Page 19

Section 5 – THE LAST MONTH – Continued
7a.

During the month of September 2014 were
there any instances in which this facility was
unable to secure EDUCATIONAL INSTRUCTION
(at locations either inside or outside of this
facility) for any young persons who are
required by state statute to receive educational
instruction?
NOTE: Do not consider planned breaks from
educational instruction (such as summer recess
or religious holidays) as an inability to provide
educational instruction.
01

Yes

No, this facility does not provide, broker,
or arrange through public schools in the
community any educational instruction ➔
Go to question 8a

No, there were no such instances ➔
Go to question 8a

b. What reasons prevented EDUCATIONAL

Page 20

8a.

During the month of September 2014 were
there any instances in which this facility was
unable to secure SUBSTANCE ABUSE
SERVICES (at locations either inside or outside
of this facility) for any young persons with a
substance use or abuse complaint or need for
substance abuse services (both urgent and
non-urgent)?
01

Yes

No, this facility does not provide or broker
substance abuse services (except through
contacting emergency services like
ambulances) ➔
Go to section 6 on page 21

No, there were no such instances ➔
Go to section 6 on page 21

b. What reasons prevented SUBSTANCE ABUSE
SERVICES from being secured for young
persons in need?
Mark (X) all that apply.

INSTRUCTION from being secured for young
persons in need?

Long-term shortages of substance abuse
service staffing at this facility

Mark (X) all that apply.

Short-term, temporary shortages of substance
abuse service staffing at this facility

Shortages, interruptions in, or absences of
contracts with substance abuse service providers
in the community

Shortages in line staff or other direct care staff
to fill in for staff who accompany young
persons to substance abuse servicess

Shortages in transportation staff or vehicles

Single or multiple instances of facility lock
downs or other security issues that prevented
substance abuse “services as usual” from
occurring for all young persons in the facility
or all young persons in specific units or wings
of this facility

Single or multiple instances of security risks
for individual young persons that prevented
substance abuse “services as usual” from
occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

Long-term shortages in educational
instructors at this facility

Short-term, temporary shortages of educational
instructors at this facility

Shortages, interruptions in, or absences of
contracts with educational instruction service
providers in the community

Shortages in line staff or other direct care staff
to fill in for staff who accompany young
persons to educational instruction

Shortages in transportation staff or vehicles

Single or multiple instances of facility lock
downs or other security issues that prevented
educational “instruction as usual” from
occurring for all young persons in the facility
or all young persons in specific units or wings
of this facility

Single or multiple instances of security risks
for individual young persons that prevented
educational “instruction as usual” from
occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

FORM CJ-15 (6-10-2013)

Section 6 – THE LAST YEAR

IMPORTANT INSTRUCTIONS
Questions 1 through 3 ask about deaths of young persons at locations either INSIDE and/or OUTSIDE this
facility during the period between October 1, 2013 and September 30, 2014.
INSIDE this facility refers to any location on the facility grounds.
OUTSIDE this facility refers to any location in the community or off facility grounds.

During the YEAR between October 1, 2013 and September 30, 2014, did ANY young persons
die while assigned a bed at this facility at a location either INSIDE or OUTSIDE of this facility?
01

Yes

➔

Go to Section 7 on page 22

How many young persons died while assigned beds at this facility during the year between
October 1, 2013 and September 30, 2014?

Person(s)

What were the cause of death, location of death, age, sex, race, date of admission to the facility,
and date of death for each young person who died while assigned a bed at this facility?

a. Cause of death
1 – Illness/natural causes
(excluding AIDS)
2 – Injury suffered prior to
placement here
3 – AIDS
4 – Suicide
5 – Homicide or manslaughter
by another resident
6 – Homicide or manslaughter
by non-resident(s)
7 – Accidental death
8 – Other – Specify in box ➔
b. Location of death
1 – Inside this facility
2 – Outside this facility

Young person 1

Young person 2

Young person 3

(1)

(2)

(3)

Code

c. Age at death (in years)
d. Sex
1 – Male
2 – Female
e. Race
1 – White, not Hispanic origin
2 – Black or African American,
not of Hispanic origin
3 – Hispanic or Latino
4 – American Indian/
Alaskan Native
5 – Asian
6 – Native Hawaiian or other
Pacific Islander
8 – Other – Specify in box ➔
f. Date of admission to
facility (mm/dd/yyyy)
g. Date of death
(mm/dd/yyyy)
FORM CJ-15 (6-10-2013)

Page 21

Section 7 – GENERAL INFORMATION
1a.

Are there any other juvenile residential facilities located within the same building or on the
same campus as the facility being reported on here?
01

Yes

➔

Go to NOTE H below

How many OTHER juvenile residential facilities are located within the same building or on the
same campus as the facility being reported on here?

Juvenile residential facilities

Does the facility being reported on here share any of the following with the other facilities
located in the same building or on the same campus?
Mark (X) all that apply.
01
02
03
04
05
06
07
08
09
10
11

The same agency affiliation
The same mailing address
The same on-site administrators
One or more staff directly caring for the young persons
One or more security staff
The same school rooms
The same infirmary
The same food services
The same dining room
The same laundry services
None of the above services are shared

Thank you for completing this questionnaire. If you would like to give us any comments on this form,
please write them at the bottom of this page or attach another sheet.
Please make a copy of this questionnaire for your records so that if we need to contact you about a
response, you will be able to refer to your copy.
NOTE
H

Please mail the completed form in the enclosed postage-paid envelope to –
U.S. Census Bureau
P.O. Box 5000
Jeffersonville, IN 47199-5000
GOVS/JRFC
or FAX toll free to: 1–888–262–3974.

Comments

Page 22

FORM CJ-15 (6-10-2013)

File Type	application/pdf
File Title	cj15p01_doc.g
File Modified	2013-09-08
File Created	2013-06-10