CJ-12 Arrest-related Deaths Quarterly Summary for Medical Exam

Attachment D:
Form CJ-12: Arrest-related Deaths Quarterly
Summary for Medical Examiner/ Coroner’s
Offices

Bureau of Justice Statistics

Arrest-related Deaths Program—2015 Pilot Study
The Death in Custody Reporting Act (DICRA) of 2013 (P.L. 113-242) requires any state receiving funds from the
Department of Justice to report information on a quarterly basis regarding the death of any person who is detained,
under arrest, or in the process of being arrested, en route to be incarcerated, or incarcerated.
In response to these reporting requirements, BJS is conducting a pilot study to determine the most efficient and
comprehensive means of identifying arrest-delated deaths and collecting information about individuals who die in the
custody of law enforcement and the circumstances surrounding those deaths. Through review of open sources,
including news outlets, official agency documents, and other publicly-available information, BJS has compiled a
preliminary list of arrest-related deaths that occurred between June 1 and August 31, 2015.
BJS is now conducting a survey of law enforcement agencies and medical examiner/ coroner’s offices with jurisdiction in
one or more of the deaths identified through open source review. The survey is designed to (1) confirm whether the
incident meets the definition of an arrest-related death and other inclusionary criteria, (2) identify any additional arrestrelated deaths that BJS did not identify during its open source review, and (3) for all confirmed arrest-related deaths,
collect additional information about the decedent and the circumstances surrounding the incident.
For the purposes of the ARD program, a death is “arrest-related” when the event causing the death (e.g., gunshot
wound, self-inflicted injury, cardiac arrest, fall from a height, drowning, etc.) occurs during an interaction with state or
local law enforcement personnel. Please exclude any deaths that occurred while the decedent was incarcerated in a jail
or prison, or any deaths where the decedent was in the custody of federal or tribal law enforcement agencies.
Deaths reportable to the ARD program include:





All homicides due to legal intervention or deaths attributed to any use of force by law enforcement personnel
(e.g., officer-involved shootings, accidental deaths caused by weapons or tactics)
All manners of death, including those resulting from homicides, suicides, natural causes, accidents, that occur
while the decedent’s freedom to leave is restricted by state or local law enforcement prior to, during, or
following an arrest, including confinements in lockups or booking centers (i.e., facilities from which arrestees
are usually transferred within 72 hours and not held beyond arraignment)
Any death that occurs during an interaction with state or local law enforcement personnel during response to
medical or mental health assistance (e.g., response to suicidal persons)

Form CJ-12, Arrest-Related Deaths Quarterly Summary, identifies each arrest-related death occurring in your jurisdiction
from June 1, 2015 through August 31, 2015. Form CJ-12A, Arrest-Related Death Incident Report, collects information on
decedent characteristics and circumstances surrounding the death for each arrest-related death identified on Form CJ12, Arrest-Related Deaths Quarterly Summary.
If you have any questions about this form or the Arrest-related Deaths Program – 2015 Pilot Study, please contact:
Michael Planty
Victimization Unit Chief
Bureau of Justice Statistics
(202) 514-9746
[email protected]

OR

Duren Banks
ARD Program Manager
RTI International
(919) 541-8026
[email protected]

Bureau of Justice Statistics

Arrest-related Deaths Program—2015 Pilot Study

FORM CJ-12

Arrest-Related Deaths Quarterly Summary

BJS has compiled a preliminary list of the following arrest-related deaths in your jurisdiction occurring from June 1
through August 31, 2015. Please confirm whether your agency has a record of these deaths; correct decedent name,
date of death, and time of death as needed; and then proceed to Form CJ-12A complete additional information about
the decedent and the circumstances surrounding the death.
Medical Examiner/ Coroner’s office name
Deaths identified from BJS open source review
Decedent name (Last, First, Middle Initial)

1

2

Doe, John A.

Date of Death

Time of Death

June 2, 2015

2:20 PM

Does your agency have a record of this death occurring from June 1 through August 31, 2015?
 Yes [Proceed to CJ-11A data collection form]
 No [State reason]
 Death did not occur between June 1 and August 31, 2015
 No record of the individual identified
 Other [Specify]
Decedent name (Last, First, Middle Initial)
Date of Death
Time of Death

Doe, John B.

July 13, 2015

1:14 AM

Does your agency have a record of this death occurring from June 1 through August 31, 2015?

 Yes [Proceed to CJ-11A data collection form]
 No [State reason]
 Death did not occur between June 1 and August 31, 2015
 No record of the individual identified
 Other [Specify]
Did your agency provide death certificates for any other deaths occurring from June 1 through August 31, 2015 that
were classified as homicides due to legal intervention?
 Yes [list below]
 No
 My organization has no means to classify homicides due to legal
intervention.
Decedent name (Last, First, Middle Initial)
Date of Death
Time of Death

3
4

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

5

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

Did your agency provide death certificates for any other deaths occurring from June 1 through August 31, 2015 that
may defined as arrest-related?

 Yes [list below]

 No

 My organization has no means to determine whether a death is arrestrelated.

6

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

7

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death