NPS-4A State Prison Inmate Death Report

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

DEATHS IN CUSTODY—2016
STATE PRISON INMATE
DEATH REPORT

Form NPS-4A
(Addendum)

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 will 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

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

E-MAIL: [email protected]
FAX (TOLL-FREE): (866) 800-9179

If you need assistance, call 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 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)
In transit to or from your facilities while under your
supervision

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



Under your jurisdiction but on AWOL or escape-status at
the time of death

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»

STATE PRISON INMATE DEATH REPORT
1.

8.

What was the inmate’s name?

LAST

FIRST

On what date was the inmate admitted to one of
your correctional facilities?

MI
MONTH

2.

DAY

YEAR

On what date did the inmate die?
2
MONTH

DAY

0

1

9.

6

For what offense(s) was the inmate being held?
a.

YEAR

b.
3.

What was the name and location of the
correctional facility involved?

c.
d.

Facility Name:

e.

Facility City:

Facility State:
10. Since admission, did the inmate ever stay
overnight in a mental health facility?

4.

What was the inmate’s date of birth?

MONTH

DAY

Yes
No
Don’t Know

YEAR

11. Where did the inmate die?
5.

What was the inmate’s sex?
Male
Female

6.

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

In a general housing unit in the facility or in a
general housing unit on prison grounds
In a segregation unit
In a special medical unit/infirmary within your
facility
In a special mental health services unit within
your facility
In a medical center outside your facility
In a mental health center outside your facility
While in transit
Elsewhere
Please Specify:

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:

«AGENCY ID»

12. 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 Q13
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
13. What was the cause of death?

CONTINUE TO Q13

*** 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]

0

14. 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 prison facility or on the prison 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)
In a special medical unit/infirmary
[PLEASE
In a special mental health services unit
SPECIFY]
In a segregation unit
On death row, special unit awaiting capital punishment
Elsewhere within the prison facility
Please Specify:

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

15. 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)
«AGENCY ID»

16. 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
Evaluated by physician/medical staff ..........................  ...............................
PLEASE PROVIDE A
Diagnostic tests (e.g., X-rays, MRI) ............................  ...............................
RESPONSE FOR
Medications .................................................................  ...............................
EACH ITEM (a–f)
Treatment/care other than medications ......................  ...............................
Surgery ........................................................................  ...............................
Confinement in special medical unit ...........................  ...............................

17. 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»