Form NPS-4 Annual Summary of Inmate Deaths in State Prisons

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

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY OF INMATE DEATHS
IN STATE PRISONS

Form NPS-4

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

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

Confined in your correctional facilities, whether housed
under your jurisdiction or that of another state



Under your jurisdiction but housed in private correctional
facilities, whether located in or out of state



Under your jurisdiction but in special facilities (e.g.,
medical/ treatment/release centers, halfway houses,
police/court lockups, or work farms)



EXCLUDE deaths of ALL persons…


Executed in your state



Confined in local jail facilities, whether located in or out of
state



Under your jurisdiction but housed in a state-operated
correctional facility in another state or in a federal facility



Under probation or parole supervision in your state

In transit to or from your facilities while under your
supervision

During 2015, how many persons died while in the custody of your state correctional facilities?
Number of deaths in 2015
Please fill out the number of deaths that occurred in calendar year 2015 above and submit this form and corresponding NPS-4A forms
to RTI International. You may submit these data in one of these ways:
ONLINE: Complete this form 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

For each inmate death, please ensure that you have submitted a STATE PRISON INMATE DEATH REPORT (NPS-4A) form.
IF NO DEATHS OCCURRED, it is still important that you complete this form and return it to RTI International.
If you need assistance, contact Matt Bensen of RTI International toll-free at (800) 344-1387 or send an e-mail to [email protected]

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 5 minutes per response, 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»