CJ-10 Death Report on Inmates in Private and Multi-Jurisdictio

OMB No. 1121-0094 Approval Expires XX/XX/201X

DEATHS IN CUSTODY—2016
DEATH REPORT ON INMATES IN
PRIVATE AND MULTI-JURISDICTIONAL JAILS

Form CJ-10

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:
RTI INTERNATIONAL

FORM COMPLETED BY:
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

E-mail

Instructions for Completion
If no deaths occurred in 2016:

You do not need to report anything at this time.

At the beginning of 2016, you will be asked to complete a summary form whether or not you had a death occurrence in 2015.
If you had more than one death in 2016:

Make copies of this form for each additional death.

Complete the entire form for each inmate death.

Once your death records are complete, there are several ways to submit a death report:
ONLINE: Complete the report online at: https://bjsdcrp.rti.org
E-MAIL: [email protected]
FAX (TOLL-FREE): (866) 800-9179

MAIL: RTI International, Attn: Data Capture
Project Number: 0215015.001.100.102.100
5265 Capital Boulevard
Raleigh, NC 27690-1652

If you need assistance, contact Matt Bensen of RTI International toll-free at (800) 344-1387 or [email protected]

What deaths should be reported?
INCLUDE deaths of ALL persons…


Confined in your jail facilities, even if housed for
another jurisdiction



Under your jurisdiction but housed in special jail
facilities (e.g., medical/treatment/release centers,
halfway houses, or work farms); or on transfer to
treatment facilities



Under your jurisdiction but out to court



In transit to or from your facilities while under your
supervision

EXCLUDE deaths of ALL persons…


Under your jurisdiction but in nonresidential communitybased programs run by your jails (e.g., electronic
monitoring, house arrest, community service, day
reporting, work programs)



Under your jurisdiction but AWOL, escaped, or on longterm transfer to another jurisdiction



In the process of arrest by your agency, but not yet
booked into your jail facility

BURDEN STATEMENT
Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. The burden of
this collection is estimated to average 30 minutes per each reported death, including reviewing instructions, searching existing data sources, gathering necessary data,
and completing and reviewing this form. Send comments regarding this burden estimate or any aspect of this survey, including suggestions for reducing this burden, to
the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531. Do not send your completed form to this address.

.
«AGENCY ID»

JAIL INMATE DEATH REPORT
1. What was the inmate’s name?
LAST

8. On what date was the inmate admitted to your jail
facility?

FIRST

MI
MONTH

DAY

YEAR

2. On what date did the inmate die?
2

2
MONTH

DAY

0

0

1

1

3

9. Was the inmate being confined in your jail facility
on behalf of any of the following?

6

YEAR

PLEASE PROVIDE A RESPONSE FOR EACH ITEM (a–c)

3. What was the name and location of the correctional
facility involved?
FacilityName:
Name:
Facility
Facility Location:
Facility City:

Facility State:

DON’T
YES NO KNOW
a. U.S. Immigration and
Customs Enforcement ................................ ..........
b. U.S. Marshals Service ................................ ..........
c. State or federal prison,
Bureau of Indian Affairs,
or any other jail jurisdiction ......................... ..........

10. For what offense(s) was the inmate being held?
4. What was the inmate’s date of birth?
MONTH

DAY

YEAR

a.
b.
c.

5. What was the inmate’s sex?
Male
Female

d.
e.

6. Was the inmate of Hispanic, Latino, or Spanish
origin?
Yes
No

7. In addition, what was the inmate’s race? Please
select one or more of the following racial
categories:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Some other race
Please Specify:

11. What was the inmate’s legal status at time of
death? (For inmates with more than one status, report
the status associated with the most serious offense.)
Convicted—new court commitment
Convicted—returned probation/parole violator
Unconvicted
Other
Please Specify:

12. Since admission, did the inmate ever stay
overnight in a mental health observation unit or an
outside mental health facility?
Yes
No
Don’t Know

«AGENCY ID»

13. Where did the inmate die?
In a general housing unit within the jail facility or in a general housing unit on jail grounds
In a segregation unit
In a special medical unit/infirmary within the jail facility
In a special mental health services unit within the jail facility
In a medical center outside the jail facility
In a mental health center outside the jail facility
While in transit
Elsewhere
Please Specify:

14. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, postmortem exam, or
review of medical records) available to establish an official cause of death?
YES
CONTINUE TO Q15
Evaluation complete—results are pending
SKIP REMAINING QUESTIONS AND SUBMIT THIS FORM - YOU WILL BE CONTACTED AT A LATER
TIME FOR THE CAUSE OF DEATH
No evaluation is planned
CONTINUE TO Q15

15. What was the cause of death?

*** Please SPECIFY cause of death—it is critical information ***

Illness—Exclude AIDS-related deaths [Specify]
Acquired Immune Deficiency Syndrome (AIDS)
Accidental alcohol/drug intoxication [Describe]
Accidental injury to self [Describe]
Accidental injury by other (e.g., vehicular
accidents during transport) [Describe]
Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) [Describe]
Homicide [Describe]
Other cause(s) [Specify]
16. Where did the incident (e.g., accident, suicide, or homicide) causing the death take place?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
In the jail facility or on the jail grounds
In the inmate’s cell/room
In a temporary holding area/lockup
In a common area within the facility (e.g., yard, library, cafeteria)
[PLEASE
In a segregation unit
SPECIFY]
In a special medical unit/infirmary
In a special mental health services unit
Elsewhere within the jail facility
Please Specify:

Outside the jail facility (e.g., while on work release or on work detail)
Elsewhere
Please Specify:

«AGENCY ID»

17. When did the incident (e.g., accident, suicide, or homicide) causing the death occur?
NOT APPLICABLE—Cause of death was illness, intoxication, or AIDS-related
Morning (6 am to Noon)
Afternoon (Noon to 6 pm)
Evening (6 pm to Midnight)
Overnight (Midnight to 6 am)
18. Excluding emergency care provided at the time of death, did the inmate receive any of the following medical
services for the medical condition that caused his/her death after admission to your correctional facilities?
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide

a.
b.
c.
d.
e.
f.

YES
NO
DON’T KNOW
Evaluation by physician/medical staff ......................................................
PLEASE PROVIDE A
Diagnostic tests (e.g., X-rays, MRI) .........................................................
RESPONSE FOR EACH
Medications ...............................................................................................
ITEM (a–f)
Treatment/care other than medications ....................................................
Surgery ......................................................................................................
Confinement in special medical unit. ........................................................

19. Was the cause of death the result of a pre-existing medical condition or did the inmate develop the condition
after admission? (If multiple conditions caused the death and any of the conditions were pre-existing, mark
“Pre-existing medical condition.”)
NOT APPLICABLE—Cause of death was accidental injury, intoxication, suicide, or homicide
Pre-existing medical condition
Deceased developed condition after admission
Could not be determined
Please add any additional notes regarding this death here:

«AGENCY ID»