ASJ, DCRP, SJIC Appendices with Table of Contents

Appendix C Attachments A-M.pdf

Annual Survey of Jails, Survey of Jails in Indian Country, Death in Custody Reporting Program (Jails)

ASJ, DCRP, SJIC Appendices with Table of Contents

OMB: 1121-0094

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1121-0094 can be found here:

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Appendix C. Attachment Table of Contents
Attachment A.

2000 Death in Custody Reporting Act (P.L. 106-297)

p. 2-3

Attachment B.

42 USC 3989g

p. 4-6

Attachment C.

Survey form CJ9A-5

p. 7-12

Attachment D.

Survey form CJ10A-5

p. 13-18

Attachment E.

Survey form CJ9A

p. 19-21

Attachment F.

Survey form CJ10A

p. 22-24

Attachment G.

Survey form CJ9

p. 25-29

Attachment H.

Survey form CJ10

p. 30-34

Attachment I.

Historical ASJ forms

p. 35-54

Attachment J.

Survey CJ5B

p. 55-59

Attachment K.

42 USC 3735

p. 60-61

Attachment L.

Mailing packet

p. 62-72

Attachment M.

Data quality follow-up scripts

p. 73-94

Attachment A. 2000 Deaths in Custody Reporting Act
(P.L. 106-297)

PUBLIC LAW 106–297—OCT. 13, 2000

114 STAT. 1045

Public Law 106–297
106th Congress
An Act
To amend the Violent Crime Control and Law Enforcement Act of 1994 to ensure
that certain information regarding prisoners is reported to the Attorney General.

Oct. 13, 2000
[H.R. 1800]

Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.

This Act may be cited as the ‘‘Death in Custody Reporting
Act of 2000’’.

Death in Custody
Reporting Act of
2000.
42 USC 13701
note.

SEC. 2. REPORTING OF INFORMATION.

Section 20104(a) of the Violent Crime Control and Law Enforcement Act of 1994 (42 U.S.C. 13704(a)) is amended—
(1) in paragraph (1)—
(A) by inserting ‘‘(A)’’ after ‘‘(1)’’; and
(B) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively;
(2) in paragraph (2), by striking ‘‘(2)’’ and inserting ‘‘(B)’’;
(3) in paragraph (3)—
(A) by striking ‘‘(3)’’ and inserting ‘‘(C)’’;
(B) by redesignating subparagraphs (A) and (B) as
clauses (i) and (ii), respectively; and
(C) by striking the period and inserting ‘‘; and’’; and
(4) by adding at the end the following new paragraph:
‘‘(2) such State has provided assurances that it will follow
guidelines established by the Attorney General in reporting,
on a quarterly basis, information regarding the death of any
person who is in the process of arrest, is en route to be incarcerated, or is incarcerated at a municipal or county jail, State
prison, or other local or State correctional facility (including
any juvenile facility) that, at a minimum, includes—
‘‘(A) the name, gender, race, ethnicity, and age of the
deceased;
‘‘(B) the date, time, and location of death; and
‘‘(C) a brief description of the circumstances surrounding the death.’’.
Approved October 13, 2000.
LEGISLATIVE HISTORY—H.R. 1800:
CONGRESSIONAL RECORD, Vol. 146 (2000):
July 24, considered and passed House.
Oct. 3, considered and passed Senate.

VerDate 11-MAY-2000

01:24 Oct 20, 2000

Jkt 069139

PO 00000

Frm 00001

Fmt 6580

Sfmt 6580

E:\PUBLAW\PUBL297.106

APPS27

PsN: PUBL297

Attachment B. 42 USC 3989g

Attachment C. Survey form CJ9A-5

OMB No. 1121-0094 Approval Expires ##/##/201#

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY ON INMATES
UNDER JAIL JURISDICTION

Form CJ-9A/5

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

Instructions for completion and submission
FOR EACH ITEM—
 If the answer to a question is “none” or “zero,” write “0” in the space provided.
 When exact numeric answers are not available, provide estimates and mark ( X ) in the checkbox beside each number that is
estimated. For example 1,234 
Please submit your completed form(s) within 30 days of receipt. You may submit information in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
EMAIL: [email protected]
FAX (TOLL-FREE): 1-866-800-9179

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 1-800-344-1387 or [email protected].

What to include and exclude in this data collection
INCLUDE—
 Confinement facilities usually administered by a local law enforcement agency, intended for adults but sometimes holding juveniles
 All jails and city/county correctional centers that hold inmates beyond arraignment. Report data on all inmates, including those held in
separate holding or lockup areas within your facilities.
 Special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
 Temporary holding or lockup facilities if they are part of your combined function.
 Inmates held for other jurisdictions, including federal authorities, state prison authorities, and other local jail jurisdictions.
EXCLUDE—
X Facilities that are exclusively used as temporary holding or lockup facilities, where inmates are generally held for less than 72 hours
and not held beyond arraignment.
X Privately operated jails and facilities operated by two or more jurisdictions (i.e., multi-jurisdictional facilities). These jails will be
contacted directly for this data collection.

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 1 hour and 15 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»

Section I — INMATE DEATHS
1.

Between January 1, 2015, and December 31, 2015, how
many persons died while under the supervision of your
jail facilities?

On December 31, 2015, how many persons under the
supervision of your jail jurisdiction were—
a. CONFINED in your jail facilities?
INCLUDE—
 Persons on transfer to treatment facilities but who
remain under your jurisdiction
 Persons held for other jurisdictions
 Persons in community-based programs (e.g., work
release, day release, or drug/alcohol treatment) who
return to jail at night
 Persons out to court while under your jurisdiction.

INCLUDE deaths of ALL persons—
 CONFINED in your jail facilities
 UNDER THE SUPERVISION of your jail facilities, but
out to court or in a special facility (e.g., hospital,
hospice, or nursing home; treatment facility; residential
community center; residential work release or house
arrest program; or release center)
 WHILE IN TRANSIT to or from your jail facilities while
under your supervision.

EXCLUDE—
X Persons under your jurisdiction who are boarded
elsewhere
X Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
X Persons in community-based programs run by your
jails (e.g., electronic monitoring, house arrest,
community service, day reporting, or work
programs) who do NOT return to jail at night.

EXCLUDE—
X Deaths of persons in the process of arrest by your
agency if they have not yet been booked into your jail
facilities. Arrest-related deaths should be reported using
a CJ-11A form.
Number of inmate deaths
a. Males ...............................................................
b. Females ..........................................................

REMINDER: IF YOUR FACILITIES HAD ONE OR MORE
DEATHS IN CALENDAR YEAR 2015, please ensure that
you have completed a 2015 CJ-9/CJ-10 (individual death
report) form for each death reported. If you need additional
CJ-9/CJ-10 forms, please go to the DCRP website
(https://bjsdcrp.rti.org), call 1-800-344-1387, or send an
email to [email protected].

INCLUDE—
 Persons in community-based programs run by your
jail jurisdiction (e.g., electronic monitoring, house
arrest, community service, day reporting, or work
programs) who do NOT return to jail at night.
EXCLUDE—
X Persons on pretrial release who are not in a
community-based program run by your jail
jurisdiction
X Persons under the supervision of probation, parole,
or other agencies
X Inmates on weekend programs that allow offenders
to serve their sentences of confinement only on
weekends (e.g., Friday–Sunday)
X Inmates participating in community-based programs
(e.g., work release, day release, or drug/alcohol
treatment) who return to jail at night.

Section II — SUPERVISED POPULATION
2.

On June 30, 2015, how many persons under the
supervision of your jail jurisdiction were CONFINED in
your jail facilities?
INCLUDE—
 Persons on transfer to treatment facilities but who
remain under your jurisdiction
 Persons held for other jurisdictions
 Persons in community-based programs (e.g., work
release, day release, or drug/alcohol treatment) who
return to jail at night
 Persons out to court while under your jurisdiction.
EXCLUDE—
X Persons under your jurisdiction who are boarded
elsewhere
X Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
X Persons in community-based programs run by your
jails (e.g., electronic monitoring, house arrest,
community service, day reporting, or work
programs) who do NOT return to jail at night.

Under jail supervision, but NOT CONFINED?

c.
4.

TOTAL (Sum of items 3a and 3b) ..............

On the weekend prior to December 31, 2015, did your jail
facilities have a weekend program?
Weekend programs allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 

Yes – How many inmates
participated? .........................

Of all the persons CONFINED in your jail facilities on
December 31, 2015 (as reported in item 3a), how many
were not U.S. citizens?
Non-U.S. citizens

Page 2

Section III — INMATE COUNTS AND MOVEMENTS OF
THE CONFINED POPULATION
6.

10. On December 31, 2015, how many persons CONFINED in
your jail facilities were—

On December 31, 2015, how many persons CONFINED in
your jail facilities were—
11
a. Adult males (age 18 or older) .....................

a. White, not of Hispanic origin ........................
b. Black or African American,
not of Hispanic origin ....................................
c. Hispanic or Latino ......................................
d. American Indian or Alaska Native,
not of Hispanic origin ....................................

b. Adult females (age 18 or older) ..................
c. Males age 17 or younger ...........................
d. Females age 17 or younger.......................

e. Asian, not of Hispanic origin ........................
f. Native Hawaiian or other Pacific
Islander, not of Hispanic origin ...................

e. TOTAL (Sum of items 6a through
6d should equal item 3a) .............................
7.

g. Two or more races, not of Hispanic origin ..
h. Additional categories in your
information system – Specify

Of all the persons age 17 or younger CONFINED in your
jail facilities on December 31, 2015 (sum of 6c and 6d),
how many were tried or awaiting trial in adult court?
Number of persons age 17
or younger held as adults ......................

i. Not known ...................................................
j. TOTAL (Sum of items 10a to 10i
should equal item 3a) ..................................

Of all persons CONFINED in your jail facilities on
December 31, 2015, how many were—



11. On December 31, 2015, how many persons CONFINED in
your jail facilities were held for—

For persons with more than one status, report the status
associated with the most serious offense.
For convicted inmates, include probation and parole
violators with no new sentence.

Count persons with multiple holds only once with priority
being federal, state, tribal, and local.


INCLUDE contractual, temporary, courtesy, or ad hoc
holds for other agencies.
a. Federal authorities

a. Convicted ..................................................

b. Unconvicted ...............................................

1. U.S. Marshals Service ....................

c. TOTAL (Sum of items 8a and 8b
should equal item 3a) .................................

2. Federal Bureau of Prisons ............
3. U.S. Immigration and Customs
Enforcement (ICE)..........................

On December 31, 2015, how many persons CONFINED in
your jail facilities, regardless of conviction status, had an
offense type of—

4. Bureau of Indian Affairs (BIA) .......
X

EXCLUDE inmates being housed for tribal
governments in item 11c below.
5. Other – Specify

For persons with more than one offense, report the most
serious type of offense.
a. Felony ........................................................

b. State prison authorities
b. Misdemeanor .............................................

1. For your state .................................

c. Other – Specify

2. For other states ..............................
c. American Indian or Alaska Native tribal governments
X

d. TOTAL (Sum of items 9a to 9c
should equal item 3a) .................................

EXCLUDE inmates being housed for the BIA in
item 11a4.

d. Other local jail jurisdictions
X
X

EXCLUDE inmates being housed for your own
jurisdiction (i.e., your own county/city inmates).
EXCLUDE inmates being housed for tribal
governments in item 11c.
1. Within your state ............................

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 

2. Outside your state .........................
e. TOTAL (Sum of items 11a to 11d) ...............
Page 3

12. a. During the 31-day period from December 1 to
December 31, 2015, on what day did your jail facilities
hold the greatest number of inmates?

15. How many persons under the supervision of your jail
jurisdiction were—
a. ADMITTED to your jail facilities during 2015?

Peak population should be equal to or greater than the
confined inmate population reported in item 3a.
December

, 2015

b. How many persons were CONFINED on that day?
Number that day
13. Between January 1, 2015, and December 31, 2015, what
was the average daily population of your jail facilities?




INCLUDE inmates who participated in weekend
programs that allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).
To calculate the average daily population, add the
number of persons for each day during the period
January 1, 2015, through December 31, 2015, and
divide the result by 365.
If daily counts are not available, estimate the average
daily population by adding the number of persons held
on the same day of each month and divide the result by
12.
If average daily population cannot be calculated as
directed above, then estimate the typical number of
persons held in your jail facilities each day.
Average daily population
a. Males....................................................

c. TOTAL (Sum of items 13a and 13b) ....

New admissions
1. Males ....................................................
2. Females ................................................
3. TOTAL (Sum of items 15a1 and 15a2)
b. DISCHARGED from your facilities during 2015?
INCLUDE—
 Persons released after a period of confinement
(e.g., sentence completion, bail/bond releases, other
pretrial releases, transfers to other jurisdictions, or
deaths)
 Persons completing their weekend sentence leaving
the facility for the last time.

Final discharges

14. On December 31, 2015, what was the total rated capacity
of your jail facilities, excluding separate temporary
holding areas?



EXCLUDE—
X Returns from escape, work release, medical
appointments/treatment facilities, furloughs,
bail/bond releases, and court appearances.

EXCLUDE—
X Temporary discharges (e.g., work releases, medical
appointments/treatment, out to courts, furloughs,
day reporters, or transfers to other facilities within
your jurisdiction).

b. Females ...............................................



INCLUDE—
 Persons officially booked into and housed in your jail
facilities by formal legal document and by the
authority of the courts or some other official agency
 Repeat offenders booked on new charges
 Persons serving a weekend sentence coming into
the facility for the first time.

1. Males ....................................................
2. Females ................................................

Rated capacity is the maximum number of beds or
inmates assigned by a rating official to a facility.
If rated capacity is not available, estimate by using the
design capacity and mark the checkbox.

3. TOTAL (Sum of items 15b1 and 15b2)

Rated capacity

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 
Page 4

Section IV — POPULATION SUPERVISED IN THE
COMMUNITY
If item 3b equals 0 (zero), SKIP to item 17.
16. On December 31, 2015, how many persons under the
supervision of your jail jurisdiction who were NOT
CONFINED participated in—
X

Section V —STAFFING
17. On December 31, 2015, how many staff employed in your
facilities were—
Count each employee only once. Classify employees with
multiple functions by the function performed most frequently.
 INCLUDE payroll staff, nonpayroll staff on the payroll of
other government agencies (e.g., health department,
school district, or court), and unpaid interns.
X EXCLUDE staff paid through contractual agreements
and community volunteers.

EXCLUDE inmates on weekend programs.

a. Electronic monitoring ................................
b. Home detention without
electronic monitoring ................................

a. Correctional officers
(Deputies, monitors, and other custody
staff who spend more than 50% of their
time with the incarcerated population.)

c. Community service ....................................
d. Day reporting .............................................

1. Males .................................................

e. Other pretrial supervision .........................

2. Females ..............................................

f. Other alternative work programs .............
X EXCLUDE inmates participating in
work release programs who return to
jail at night.

b. All other staff
(Administrators, clerical and maintenance
staff, educational staff, professional and
technical staff, and other staff – unspecified
who spend more than 50% of their time in
the facility.)

g. Alcohol/drug treatment programs ............
X EXCLUDE inmates participating in
alcohol/drug treatment programs
who are confined in jail.

1. Males ..................................................

h. Other programs outside of
jail facilities – Specify

2. Females ..............................................
i. TOTAL (Sum of items 16a to 16h
should equal item 3b) ..................................

c. TOTAL (Sum of items 17a and 17b) ............

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 
Page 5

Attachment D. Survey form CJ10A-5

OMB No. 1121-0094 Approval Expires ##/##/201#

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY ON INMATES IN
PRIVATE AND MULTIJURISDICTIONAL JAILS

Form CJ-10A/5

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

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 1-800-344-1387 or [email protected].

What to include and exclude in this data collection
INCLUDE—
 Confinement facilities—including detention centers, jails, and other correctional facilities—intended for adults but sometimes holding
juveniles, that are either privately owned and operated or administered by two or more governments (or a board composed of
representatives from two or more governments).
 All jails and city/county correctional centers that hold inmates beyond arraignment. Report data on all inmates, including those held in
separate holding or lockup areas within your facilities.
 Special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
 Temporary holding or lockup facilities if they are part of your combined function.
 Inmates held for other jurisdictions, including federal authorities, state prison authorities, and other local jail jurisdictions.
EXCLUDE—
X Facilities that are exclusively used as temporary holding or lockup facilities, where inmates are generally held for less than 72 hours
and not held beyond arraignment.

«AGENCY ID»

Section I — INMATE DEATHS
1.

Between January 1, 2015, and December 31, 2015, how
many persons died while under the supervision of this
facility?

On December 31, 2015, how many persons under the
supervision of your jail were—
a. CONFINED in this facility?
INCLUDE—
 Persons on transfer to treatment facilities but who
remain under your jurisdiction
 Persons held for other jurisdictions
 Persons in community-based programs (e.g., work
release, day release, or drug/alcohol treatment) who
return to jail at night
 Persons out to court while under your jurisdiction.

INCLUDE deaths of ALL persons—
 CONFINED in this facility
 UNDER THE SUPERVISION of this facility, but out to
court or in a special facility (e.g., hospital, hospice, or
nursing home; treatment facility; residential community
center; residential work release or house arrest
program; or release center)
 WHILE IN TRANSIT to or from this facility while under
your supervision.

EXCLUDE—
X Persons under your jurisdiction who are boarded
elsewhere
X Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
X Persons in community-based programs run by this
facility (e.g., electronic monitoring, house arrest,
community service, day reporting, or work
programs) who do NOT return to jail at night.

EXCLUDE—
X Deaths of persons in the process of arrest by your
agency if they have not yet been booked into this
facility. Arrest-related deaths should be reported using a
CJ-11A form.
Number of inmate deaths
a. Males ...............................................................
b.

b. Females ..........................................................

INCLUDE—
 Persons in community-based programs run by this
facility (e.g., electronic monitoring, house arrest,
community service, day reporting, or work
programs) who do NOT return to jail at night.

REMINDER: IF THIS FACILITY HAD ONE OR MORE
DEATHS IN CALENDAR YEAR 2015, please ensure that
you have completed a 2015 CJ-9/CJ-10 (individual death
report) form for each death reported. If you need additional
CJ-9/CJ-10 forms, please go to the DCRP website
(https://bjsdcrp.rti.org), call 1-800-344-1387, or send an
email to [email protected].

EXCLUDE—
X Persons on pretrial release who are not in a
community-based program run by this facility
X Persons under the supervision of probation, parole,
or other agencies
X Inmates on weekend programs that allow offenders
to serve their sentences of confinement only on
weekends (e.g., Friday–Sunday)
X Inmates participating in community-based programs
(e.g., work release, day release, or drug/alcohol
treatment) who return to jail at night.

Section II — SUPERVISED POPULATION
2.

On June 30, 2015, how many persons under the
supervision of your jail were CONFINED in this facility?
INCLUDE—
 Persons on transfer to treatment facilities but who
remain under your jurisdiction
 Persons held for other jurisdictions
 Persons in community-based programs (e.g., work
release, day release, or drug/alcohol treatment) who
return to jail at night
 Persons out to court while under your jurisdiction.
EXCLUDE—
X Persons under your jurisdiction who are boarded
elsewhere
X Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
X Persons in community-based programs run by this
facility (e.g., electronic monitoring, house arrest,
community service, day reporting, or work
programs) who do NOT return to jail at night.

Under jail supervision, but NOT CONFINED?

c.
4.

TOTAL (Sum of items 3a and 3b) ..............

On the weekend prior to December 31, 2015, did this
facility have a weekend program?
Weekend programs allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).

Yes – How many inmates
participated? .........................

Of all the persons CONFINED in this facility on December
31, 2015 (as reported in item 3a), how many were not U.S.
citizens?
Non-U.S. citizens

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 
Page 2

Section III — INMATE COUNTS AND MOVEMENTS OF
THE CONFINED POPULATION
6.

10. On December 31, 2015, how many persons CONFINED in
this facility were—

On December 31, 2015, how many persons CONFINED in
this facility were—
11
a. Adult males (age 18 or older) .....................

a. White, not of Hispanic origin ........................
b. Black or African American,
not of Hispanic origin ....................................

b. Adult females (age 18 or older) ..................

c. Hispanic or Latino ......................................
d. American Indian or Alaska Native,
not of Hispanic origin ....................................

c. Males age 17 or younger ...........................
d. Females age 17 or younger.......................

e. Asian, not of Hispanic origin ........................
f. Native Hawaiian or other Pacific
Islander, not of Hispanic origin ...................

e. TOTAL (Sum of items 6a through
6d should equal item 3a) .............................
7.

g. Two or more races, not of Hispanic origin ..
h. Additional categories in your
information system – Specify

Of all the persons age 17 or younger CONFINED in this
facility on December 31, 2015 (sum of 6c and 6d), how
many were tried or awaiting trial in adult court?
Number of persons age 17
or younger held as adults ......................

i. Not known ...................................................
j. TOTAL (Sum of items 10a to 10i
should equal item 3a) ..................................

Of all persons CONFINED in this facility on
December 31, 2015, how many were—



For persons with more than one status, report the status
associated with the most serious offense.
For convicted inmates, include probation and parole
violators with no new sentence.

11. On December 31, 2015, how many persons CONFINED in
this facility were held for—
Count persons with multiple holds only once with priority
being federal, state, tribal, and local.


INCLUDE contractual, temporary, courtesy, or ad hoc
holds for other agencies.
a. Federal authorities

a. Convicted ..................................................
b. Unconvicted ...............................................

1. U.S. Marshals Service ....................
c. TOTAL (Sum of items 8a and 8b
should equal item 3a) .................................
9.

2. Federal Bureau of Prisons ............
3. U.S. Immigration and Customs
Enforcement (ICE)..........................

On December 31, 2015, how many persons CONFINED in
this facility, regardless of conviction status, had an
offense type of—

4. Bureau of Indian Affairs (BIA) .......
X

EXCLUDE inmates being housed for tribal
governments in item 11c below.
5. Other – Specify

For persons with more than one offense, report the most
serious type of offense.
a. Felony ........................................................

b. State prison authorities

b. Misdemeanor .............................................

1. For your state .................................
c. Other – Specify

2. For other states ..............................
c. American Indian or Alaska Native tribal governments
X

d. TOTAL (Sum of items 9a to 9c
should equal item 3a) .................................

EXCLUDE inmates being housed for the BIA in
item 11a4.

d. Other local jail jurisdictions
X
X

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 

2. Outside your state .........................
e. TOTAL (Sum of items 11a to 11d) ...............
Page 3

12. a. During the 31-day period from December 1 to
December 31, 2015, on what day did this facility hold
the greatest number of inmates?

15. How many persons under the supervision of your jail
were—
a. ADMITTED to this facility during 2015?

Peak population should be equal to or greater than the
confined inmate population reported in item 3a.
December

, 2015

b. How many persons were CONFINED on that day?
Number that day

EXCLUDE—
X Returns from escape, work release, medical
appointments/treatment facilities, furloughs,
bail/bond releases, and court appearances.

13. Between January 1, 2015, and December 31, 2015, what
was the average daily population of this facility?




INCLUDE—
 Persons officially booked into and housed in this
facility by formal legal document and by the authority
of the courts or some other official agency
 Repeat offenders booked on new charges
 Persons serving a weekend sentence coming into
the facility for the first time.

INCLUDE inmates who participated in weekend
programs that allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).
To calculate the average daily population, add the
number of persons for each day during the period
January 1, 2015, through December 31, 2015, and
divide the result by 365.
If daily counts are not available, estimate the average
daily population by adding the number of persons held
on the same day of each month and divide the result by
12.
If average daily population cannot be calculated as
directed above, then estimate the typical number of
persons held in this facility each day.
Average daily population
a. Males....................................................

New admissions
1. Males ....................................................
2. Females ................................................
3. TOTAL (Sum of items 15a1 and 15a2)
b. DISCHARGED from this facility during 2015?
INCLUDE—
 Persons released after a period of confinement
(e.g., sentence completion, bail/bond releases, other
pretrial releases, transfers to other jurisdictions, or
deaths)
 Persons completing their weekend sentence leaving
the facility for the last time.
EXCLUDE—
X Temporary discharges (e.g., work releases, medical
appointments/treatment, out to courts, furloughs,
day reporters, or transfers to other facilities within
your jurisdiction).

b. Females ...............................................
c. TOTAL (Sum of items 13a and 13b) ....

Final discharges
14. On December 31, 2015, what was the total rated capacity
of this facility, excluding separate temporary holding
areas?



1. Males ....................................................
2. Females ................................................

Rated capacity is the maximum number of beds or
inmates assigned by a rating official to a facility.
If rated capacity is not available, estimate by using the
design capacity and mark the checkbox.

3. TOTAL (Sum of items 15b1 and 15b2)

Rated capacity

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 
Page 4

Section IV — POPULATION SUPERVISED IN THE
COMMUNITY
If item 3b equals 0 (zero), SKIP to item 17.

Section V —STAFFING
17. On December 31, 2015, how many staff employed in this
facility were—

16. On December 31, 2015, how many persons under the
supervision of this facility who were NOT CONFINED
participated in—
X

Count each employee only once. Classify employees with
multiple functions by the function performed most frequently.
 INCLUDE payroll staff, nonpayroll staff on the payroll of
other government agencies (e.g., health department,
school district, or court), and unpaid interns.
X EXCLUDE staff paid through contractual agreements
and community volunteers.

EXCLUDE inmates on weekend programs.

a. Electronic monitoring ................................
b. Home detention without
electronic monitoring ................................

a. Correctional officers
(Deputies, monitors, and other custody
staff who spend more than 50% of their
time with the incarcerated population.)

c. Community service ....................................
d. Day reporting .............................................

1. Males .................................................

e. Other pretrial supervision .........................

2. Females ..............................................

f. Other alternative work programs .............
X EXCLUDE inmates participating in
work release programs who return to
jail at night.

g. Alcohol/drug treatment programs ............
X EXCLUDE inmates participating in
alcohol/drug treatment programs
who are confined in jail.

1. Males ..................................................

h. Other programs outside of
jail facilities – Specify

2. Females ..............................................
i. TOTAL (Sum of items 16a to 16h
should equal item 3b) ..................................

c. TOTAL (Sum of items 17a and 17b) ............

When exact numeric answers are not available, provide
estimates and mark ( X ) in the checkbox beside each number
that is estimated. For example 1,234 
Page 5

Attachment E. Survey form CJ9A

OMB No. 1121-0094 Approval Expires ##/##/201#
U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY ON INMATES
UNDER JAIL JURISDICTION

Form CJ-9A

RTI INTERNATIONAL

FORM COMPLETED BY—
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

Instructions for completion and submission
FOR EACH ITEM—
 If the answer to a question is “none” or “zero,” write “0” in the space provided.
 When exact numeric answers are not available, provide estimates and mark ( X ) in the checkbox beside each number that is
estimated. For example 1,234 
Please submit your completed form(s) within 30 days of receipt. You may submit your annual summary in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
EMAIL: [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 1-800-344-1387 or [email protected].

What to include and exclude in this data collection
INCLUDE—
 Confinement facilities usually administered by a local law enforcement agency, intended for adults but sometimes holding juveniles.
 All jails and city/county correctional centers that hold inmates beyond arraignment. Report data on all inmates, including those held in
separate holding or lockup areas within your facilities.
 Special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
 Temporary holding or lockup facilities if they are part of your combined function.
 Inmates held for other jurisdictions, including federal authorities, state prison authorities, and other local jail jurisdictions.
EXCLUDE—
X Facilities that are exclusively used as temporary holding or lockup facilities, where inmates are generally held for less than 72 hours
and not held beyond arraignment.
X Privately operated jails and facilities operated by two or more jurisdictions (i.e., multi-jurisdictional facilities). These jails will be
contacted directly for this data collection.

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 15 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»

INMATE COUNTS AND DEATHS

1. On December 31, 2015, how many persons under the
supervision of your jail jurisdiction were CONFINED in
your jail facilities?
INCLUDE—





X
X

Persons under your jurisdiction who are boarded
elsewhere
Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
Persons in community-based programs run by your
jails (e.g., electronic monitoring, house arrest,
community service, day reporting, or work programs)
who do NOT return to jail at night.

Inmates on
December 31,
2015

Males:

Estimate

Females:

Estimate

2. How many persons under the supervision of your jail
jurisdiction were ADMITTED to your jail facilities during
2015?
INCLUDE—




Persons officially booked into and housed in your jail
facilities by formal legal document and by the
authority of the courts or some other official agency
Repeat offenders booked on new charges
Persons serving a weekend sentence coming into the
facility for the first time.

Returns from escape, work release, medical
appointments/treatment facilities, furloughs, bail/bond
releases, and court appearances.

New ANNUAL
admissions
during 2015

INCLUDE contractual, temporary, courtesy, or ad hoc
holds for other agencies.
Count persons with multiple holds only once with priority
being federal, state, tribal, and local.

a. U.S. Immigration and
Customs Enforcement:

Estimate

b. U.S. Marshals Service:

Estimate

c. All other holds (state and
federal prison, Bureau of
Indian Affairs, or any holds
for other jail jurisdictions):

Estimate

4. Between January 1, 2015, and December 31, 2015, what
was the average daily population of your jail facilities?


INCLUDE inmates who participated in weekend
programs that allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).
To calculate the average daily population, add the
number of persons for each day between January 1,
2015, and December 31, 2015, and divide the result by
365.
If daily counts are not available, estimate the average
daily population by adding the number of persons held
on the same day of each month and divide the result by
12.
If average daily population cannot be calculated as
directed above, then estimate the typical number of
persons held in your jail confinement facilities each day.



Average daily
population
during 2015

Males:

Estimate

Females:

Estimate

5. Between January 1, 2015, and December 31, 2015, how
many persons died while under the supervision of your
jail facilities?
INCLUDE deaths of ALL persons—

EXCLUDE—
X




Persons on transfer to treatment facilities but who
remain under your jurisdiction
Persons held for other jurisdictions
Persons in community-based programs (e.g., work
release, day release, or drug/alcohol treatment) who
return to jail at night
Persons out to court while under your jurisdiction.

EXCLUDE—
X

3. On December 31, 2015, how many persons CONFINED in
your jail facilities were held for—

Males:

Estimate

Females:

Estimate






CONFINED in your jail facilities
UNDER THE SUPERVISION of your jail facilities, but
out to court or in special facilities (e.g., hospital,
hospice, or nursing home; treatment facility;
residential community center; residential work release
or house arrest program; or release center)
WHILE IN TRANSIT to or from your jail facilities while
under your supervision.

EXCLUDE—
X

Number of
inmate
deaths
during 2015

Deaths of persons in the process of arrest by your
agency if they have not yet been booked into your jail
facilities. Arrest-related deaths should be reported
using a CJ-11A form.

Males:
Females:

«AGENCY ID»

Attachment F. Survey form CJ10A

OMB No. 1121-0094 Approval Expires ##/##/201#
U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT:

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY ON INMATES IN
PRIVATE AND MULTIJURISDICTIONAL JAILS

Form CJ-10A

RTI INTERNATIONAL

FORM COMPLETED BY—
Name

Title

Official
Address

Telephone

City

FAX

State

Zip

Instructions for completion and submission
FOR EACH ITEM—
 If the answer to a question is “none” or “zero,” write “0” in the space provided.
 When exact numeric answers are not available, provide estimates and mark ( X ) in the checkbox beside each number that is
estimated. For example 1,234 
Please submit your completed form(s) within 30 days of receipt. You may submit your annual summary in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
EMAIL: [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 1-800-344-1387 or [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 15 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»

INMATE COUNTS AND DEATHS

1. On December 31, 2015, how many persons under the
supervision of your jail were CONFINED in this facility?



INCLUDE—





EXCLUDE—
X
X
X

Persons under your jurisdiction who are boarded
elsewhere
Inmates who are AWOL, escaped, or on long-term
transfer to other jurisdictions
Persons in community-based programs run by this
facility (e.g., electronic monitoring, house arrest,
community service, day reporting, or work programs)
who do NOT return to jail at night.

Inmates on
December 31,
2015

3. On December 31, 2015, how many persons CONFINED in
this facility were held for—

Males:

Estimate

Females:

Estimate

INCLUDE contractual, temporary, courtesy, or ad hoc
holds for other agencies.
Count persons with multiple holds only once with priority
being federal, state, tribal, and local.



a. U.S. Immigration and
Customs Enforcement:

Estimate

b. U.S. Marshals Service:

Estimate

c. All other holds (state and
federal prison, Bureau of
Indian Affairs, or any holds
for other jail jurisdictions):

Estimate

4. Between January 1, 2015, and December 31, 2015, what
was the average daily population of this facility?


INCLUDE inmates who participated in weekend
programs that allow offenders to serve their sentences
of confinement only on weekends (e.g., Friday–Sunday).
To calculate the average daily population, add the
number of persons for each day between January 1,
2015, and December 31, 2015, and divide the result by
365.
If daily counts are not available, estimate the average
daily population by adding the number of persons held
on the same day of each month and divide the result by
12.
If average daily population cannot be calculated as
directed above, then estimate the typical number of
persons held in this facility each day.



2. How many persons under the supervision of your jail were
ADMITTED to this facility during 2015?



INCLUDE—




Persons officially booked into and housed in this
facility by formal legal document and by the authority
of the courts or some other official agency
Repeat offenders booked on new charges
Persons serving a weekend sentence coming into the
facility for the first time.

EXCLUDE—
X

Returns from escape, work release, medical
appointments/treatment facilities, furloughs, bail/bond
releases, and court appearances.

New ANNUAL
admissions
during 2015

Males:

Estimate

Females:

Estimate

Average daily
population
during 2015

Males:

Estimate

Females:

Estimate

5. Between January 1, 2015, and December 31, 2015, how
many persons died while under the supervision of this
facility?
INCLUDE deaths of ALL persons—





CONFINED in this facility
UNDER THE SUPERVISION of this facility, but out to
court or in special facilities (e.g., hospital, hospice, or
nursing home; treatment facility; residential
community center; residential work release or house
arrest program; or release center)
WHILE IN TRANSIT to or from this facility while
under your supervision.

EXCLUDE—
X

Number of
inmate
deaths
during 2015

Deaths of persons in the process of arrest by your
agency if they have not yet been booked into this
facility. Arrest-related deaths should be reported
using a CJ-11A form.

Males:
Females:

«AGENCY ID»

Attachment G. Survey form CJ9

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

DEATHS IN CUSTODY—2016
DEATH REPORT ON INMATES
UNDER JAIL JURISDICTION

Form CJ-9

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…

EXCLUDE deaths of ALL persons…



Confined in your jail facilities, whether housed under
your own or another jurisdiction



Confined in facilities operated by two or more
jurisdictions or those held in privately operated jails



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



Under your jurisdiction but out to court



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

In transit to or from your facilities while under your
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»

LOCAL JAIL INMATE DEATH REPORT

1. What was the inmate’s name?
LAST

8. On what date was the inmate admitted to a facility
under your jurisdiction?

FIRST

MI
MONTH

DAY

YEAR

2. On what date did the inmate die?
2
MONTH

DAY

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

YEAR

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

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

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?

a.
b.

MONTH

DAY

YEAR

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

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:

d.
e.

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
15. What was the cause of death?

CONTINUE TO Q15
*** Please SPECIFY cause of death—it is critical information ***

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
Medications ...............................................................................................
EACH 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»

Attachment H. Survey form CJ10

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

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

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

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:

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»

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»

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. ........................................................

«AGENCY ID»

Attachment I. Historical ASJ forms – CJ5DA, CJ5D,
CJ5A, CJ5

CJ-5

OMB No. 1121-0094: Approval Expires 5/31/2016

CJ-5

RETURN
TO

U.S. Census Bureau
Governments Division
Washington, DC 20233-6800

FORM
(3-7-2014)

U.S. DEPARTMENT OF JUSTICE

2014 ANNUAL
SURVEY OF JAILS

BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

U.S. DEPARTMENT OF COMMERCE
ECONOMICS AND STATISTICS ADMINISTRATION
U.S. CENSUS BUREAU

DATA SUPPLIED BY
Name
OFFICIAL
ADDRESS
TELEPHONE

Title
Number and street or P.O. box/Route number
Area code

Number

Extension

City
FAX
NUMBER

State ZIP Code
Area Code

Number

E-MAIL
ADDRESS

(Please correct any error in name, mailing address, and ZIP Code)

GENERAL INFORMATION
• If you have any questions, call the U.S. Census Bureau at 1–800–253–2078, or e-mail [email protected].
• Please complete the questionnaire before July 31, 2014 using the web-reporting option (see the web flyer for details), by
mailing the completed form to the U.S. Census Bureau in the enclosed envelope, or by FAXing all pages to
1–888–262–3974.
• Please retain a copy of the completed form for your records.

What types of facilities are included in this survey?
Confinement facilities usually administered by a local law enforcement agency, intended for adults but sometimes
holding juveniles.
• INCLUDE jails and city/county correctional centers.
• INCLUDE special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
• INCLUDE temporary holding or lockup facilities if they are part of your combined function.
• EXCLUDE temporary holding or lockup facilities that are not part of your combined function from which inmates are
usually transferred within 72 hours and not held beyond arraignment. If your only function is a temporary holding or
lockup facility, DO NOT complete this form – contact Leslie Miller at 1–800–253–2078.
• EXCLUDE facilities reporting to form CJ-5D, which collects data from jail jurisdictions that are selected with certainty to
participate in the Annual Survey of Jails.

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 1 1/4 hours 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.

FORM CJ-5 (3-7-2014)

REPORTING INSTRUCTIONS
• If the answer to a question is "not available" or "unknown," write "DK" in the space provided.
• If the answer to a question is "not applicable," write "NA" in the space provided.
• If the answer to a question is "none" or "zero," write "0" in the space provided.
• When exact numeric answers are not available, provide estimates and mark (X) in the
box beside each figure that is estimated. For example 1,234 X

Section I — SUPERVISED POPULATION

I.2. Of all persons under your jail supervision
reported in item I.1c, how many were not U.S.
citizens?

I.1. On June 30, 2014, how many persons under the
supervision of your jail jurisdiction were —

Non-US citizens

a. CONFINED in your jail facilities?
I.3. On the weekend prior to June 30, 2014, did your
jail jurisdiction have a weekend program?

• INCLUDE persons on transfer to treatment
facilities but who remain under your
jurisdiction.

• Weekend programs allow offenders to serve their

• INCLUDE persons held for other jurisdictions.

sentences of confinement only on weekends (e.g.,
Friday–Sunday).

• INCLUDE persons in community-based programs
(e.g., work release, day release, drug/alcohol
treatment) who return to jail at night.

Yes – How many inmates
participated?

• EXCLUDE any persons housed in facilities
operated by two or more jurisdictions or those
housed in privately operated jails.

Section II — INMATE COUNTS AND MOVEMENTS
OF THE CONFINED POPULATION

• EXCLUDE inmates on AWOL, escape, or
long-term transfer to other jurisdictions.
• EXCLUDE inmates being boarded out to another
county or held in another facility not operated by
your jail jurisdiction.

II.1. On June 30, 2014, how many persons CONFINED
in your jail facilities were —
a. Adult males (age 18 or
older) . . . . . . . . . . . . . . . . . . .
b. Adult females (age 18 or
older) . . . . . . . . . . . . . . . . . . .

b. Under jail supervision but NOT CONFINED?
• INCLUDE all persons in community-based programs
run by your jails (e.g., electronic monitoring, house
arrest, community service, day reporting, and work
programs).

c. Males under age 18 . . . . . . .
d. Females under age 18 . . . . .

• EXCLUDE persons on pretrial release who are not in
a community based program run by your jails.
• EXCLUDE persons under supervision of probation,
parole or other agencies.
• EXCLUDE inmates on weekend programs.
Weekend programs allow offenders to serve
their sentences of confinement only on weekends
(e.g., Friday–Sunday).

e. TOTAL (Sum of items II.1a to
II.1d should equal item I.1a) . . . .
II.2. Of all persons under the age of 18 CONFINED in
your jail facilities on June 30, 2014 (items II.1c
and II.1d), how many were tried, or awaiting
trial, in adult court?
Number of persons under
age 18 held as adults. . . . . . . . . .

• EXCLUDE inmates participating in work release
programs who return to the jail at night.

c. Total (Sum of items
I.1a and I.1b) . . . . . . . . . . . . .
Page 2

FORM CJ-5 (3-7-2014)

II.3. Of all persons CONFINED in your jail facilities
on June 30, 2014, how many were —

II.5. On June 30, 2014, how many persons
CONFINED in your jail facilities were held for —
• For persons with a multiple hold, count them only
once with priority being Federal, State, and local.

• For persons with more than one status, report the
status with the most serious offense.
• For convicted inmates include probation and parole
violators with no new sentence.

a. Federal authorities
1. U.S. Marshals Service . .

a. Convicted. . . . . . . . . . . . . .
2. Federal Bureau of Prisons
How many were —
1. Unsentenced inmates
or awaiting sentencing. . . .

3. U.S. Immigration and
Customs Enforcement
(I.C.E.). . . . . . . . . . . . . . .

2. Sentenced inmates. . . . . .

4. Bureau of Indian Affairs .
5. Other – Specify

b. Unconvicted . . . . . . . . . . .
How many were —

b. State prison authorities

1. Awaiting trial/
arraignment. . . . . . . . . . .

1. For your state . . . . . . . . .

2. Awaiting transfer/hold
for other authorities. . . . . .

2. For other states . . . . . . .
c. Other local jail jurisdictions

3. Other . . . . . . . . . . . . . . .

• EXCLUDE inmates being housed for your own
jurisdiction (i.e., your own county/city inmates).

c. TOTAL (Sum of items II.3a
and II.3b should equal item I.1a)

1. Within your state . . . . . .
II.4. On June 30, 2014, how many persons
CONFINED in your jail facilities were —

2. Outside your state . . . . .
d. TOTAL (Sum of items II.5a
to II.5c) . . . . . . . . . . . . . . . . .

a. White, not of Hispanic
origin . . . . . . . . . . . . . . . . . .
b. Black or African American,

not of Hispanic origin. . . . . . . .

II.6. a. During the 30-DAY period from June 1 to
June 30, 2014, on what day did your facility
hold the greatest number of inmates?

c. Hispanic or Latino . . . . . . .

• Peak population should be equal to or greater than
the confined inmate population reported in item I.1a.

d. American Indian/Alaska
Native, not of Hispanic origin .

June
e. Asian, not of Hispanic origin . .

, 2014

b. How many persons were CONFINED on
that day?

f. Native Hawaiian or Other
Pacific Islander, not of
Hispanic origin . . . . . . . . . . . .

Number that day

g. Two or more races, not
of Hispanic origin . . . . . . . . . .
h. Additional categories in your
information system — Specify

i. Not known . . . . . . . . . . . . .
j. TOTAL (Sum of items II.4a
to II.4i should equal item I.1a) . .

Page 3

FORM CJ-5 (3-7-2014)

Section III — POPULATION SUPERVISED
IN THE COMMUNITY

II.7. Between July 1, 2013, and June 30, 2014,
what was the average daily population of all
jail confinement facilities operated by your
jurisdiction?

If item I.1b equals 0 (zero), STOP HERE.
III.1. On June 30, 2014, how many persons under
your jail supervision who were NOT CONFINED,
participated in —

• Include inmates who participated in weekend
programs that allow offenders to serve their
sentences of confinement only on weekends
(e.g., Friday-Sunday).

• EXCLUDE inmates on weekend programs.

• To calculate the average daily population, add the
number of persons for each day during the period
July 1, 2013, through June 30, 2014, and divide
the result by 365.

a. Electronic monitoring. . . .
b. Home detention without
electronic monitoring . . . .

Average daily population

c. Community service. . . . . .

II.8. On June 30, 2014, what was the total jail
capacity of your jail facilities?

d. Day reporting

a. Rated capacity
(The maximum number of beds
or inmates assigned by a rating
official to a facility, excluding
separate temporary holding
areas.) . . . . . . . . . . . . . . . .

.........

e. Other pretrial supervision
f. Other alternative work
programs . . . . . . . . . . . . .
• EXCLUDE inmates participating in work release
programs who return to the jail at night.

b. Operational capacity
(The number of inmates that can
be accommodated based on
staff, existing programs and
services in institutions within your
jurisdiction. Also known as
“budget” capacity.) . . . . . . . .

g. Alcohol/drug treatment
programs . . . . . . . . . . . . .
• EXCLUDE inmates participating in alcohol/drug
treatment programs who are confined in the jail.
h. Other programs outside
of jail facilities – Specify

c. Design capacity
(The number of inmate’s
planners or architects intended
for all jail facilities in your
jurisdiction.) . . . . . . . . . . . . .

i. TOTAL (Sum of items III.1a to
III.1h should equal item I.1b) .

II.9. During the WEEK of June 24 to June 30, 2014,
how many persons were —

III.2. On June 30, 2014, how many persons under
your jail supervision who were NOT
CONFINED were —

a. New admissions to your jail facilities?
• INCLUDE persons officially booked into and housed
in your facility by formal legal document and by the
authority of the courts or some other official agency.
• INCLUDE those persons serving a weekend
sentence coming into the facility for the first time.
• EXCLUDE returns from escape, work release,
medical appointments/treatment facilities, bail and
court appearances.

a. Adult males (age 18 or
older). . . . . . . . . . . . . . . . . .
b. Adult females (age 18 or
older). . . . . . . . . . . . . . . . . .
c. Males under age 18. . . . . .

New admissions

d. Females under age 18. . . .

b. Final discharges from your jail facilities?

e. TOTAL (Sum of items III.2a to
III.2d should equal item I.1b) . .

• INCLUDE all persons released after a period of
confinement (e.g., sentence completion, bail/bond
releases, other pretrial releases, transfers to other
jurisdictions, and deaths).
• INCLUDE those persons completing their weekend
sentence leaving the facility for the last time.
• EXCLUDE temporary discharges (e.g., work
releases, medical appointments/treatment, to courts,
furloughs, day reporters, and transfers to other
facilities within your jurisdiction).

III.3. Of all persons under your jail supervision who
were NOT CONFINED on June 30, 2014, how
many were —
a. Convicted

............

b. Unconvicted . . . . . . . . . . .
c. TOTAL (Sum of items III.3a and
III.3b should equal item I.1b) . .

Final discharges

Page 4

CJ-5D

OMB No. 1121-0094: Approval Expires 5/31/2016

CJ-5D

RETURN
TO

U.S. Census Bureau
Governments Division
Washington, DC 20233-6800

FORM
(3-7-2014)

U.S. DEPARTMENT OF JUSTICE

2014 ANNUAL
SURVEY OF JAILS

BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

U.S. DEPARTMENT OF COMMERCE
ECONOMICS AND STATISTICS ADMINISTRATION
U.S. CENSUS BUREAU

DATA SUPPLIED BY
Name
OFFICIAL
ADDRESS
TELEPHONE

Title
Number and street or P.O. box/Route number
Area code

Number

Extension

City
FAX
NUMBER

State ZIP Code
Area Code

Number

E-MAIL
ADDRESS

(Please correct any error in name, mailing address, and ZIP Code)

What types of facilities are included in this survey?
Confinement facilities in jurisdictions included with certainty in the Annual Survey of Jails. Confinement facilities are usually
administered by a local law enforcement agency, intended for adults but sometimes holding juveniles.
Confinement facilities
• INCLUDE jails and city/county correctional centers.
• INCLUDE special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
• INCLUDE temporary holding or lockup facilities if they are part of your combined function.
• EXCLUDE temporary holding or lockup facilities that are not part of your combined function from which inmates are
usually transferred within 72 hours and not held beyond arraignment. If your only function is a temporary holding or
lockup facility, DO NOT complete this form – contact Leslie Miller at 1–800–253–2078.
Certainty jurisdictions
• INCLUDE facilities in jail jurisdictions that held juvenile inmates at the time of the 2005 Census of Jail Inmates and had an
average daily population of 500 or more inmates during the 12 months ending June 30, 2005.
• INCLUDE facilities in jail jurisdictions that held only adult inmates and had an average daily population of 750 or more at the
time of the 2005 Census of Jail Inmates.

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 2 hours 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.

FORM CJ-5D (3-7-2014)

Section I — SUPERVISED POPULATION

I.2. Of all persons under your jail supervision
reported in item I.1c, how many were not U.S.
citizens?

I.1. On June 30, 2014, how many persons under the
supervision of your jail jurisdiction were —

Non-US citizens

a. CONFINED in your jail facilities?
I.3. On the weekend prior to June 30, 2014, did your
jail jurisdiction have a weekend program?

• INCLUDE persons on transfer to treatment
facilities but who remain under your
jurisdiction.

• Weekend programs allow offenders to serve their

• INCLUDE persons held for other jurisdictions.

sentences of confinement only on weekends (e.g.,
Friday–Sunday).

• INCLUDE persons in community-based programs
(e.g., work release, day release, drug/alcohol
treatment) who return to jail at night.

Yes – How many inmates
participated?

• EXCLUDE any persons housed in facilities
operated by two or more jurisdictions or those
housed in privately operated jails.

Section II — INMATE COUNTS AND MOVEMENTS
OF THE CONFINED POPULATION

c. Males under age 18 . . . . . . .
d. Females under age 18. . . . .

• EXCLUDE inmates participating in work release
programs who return to the jail at night.

c. Total (Sum of items
I.1a and I.1b) . . . . . . . . . . . . .
Page 2

FORM CJ-5D (3-7-2014)

II.3. Of all persons CONFINED in your jail facilities
on June 30, 2014, how many were —

II.5. On June 30, 2014, how many persons
CONFINED in your jail facilities were held for —
• For persons with a multiple hold, count them only
once with priority being Federal, State, and local.

• For persons with more than one status, report the
status with the most serious offense.
• For convicted inmates include probation and parole
violators with no new sentence.

a. Federal authorities
1. U.S. Marshals Service . .

a. Convicted. . . . . . . . . . . . . .
2. Federal Bureau of Prisons
How many were —
1. Unsentenced inmates
or awaiting sentencing. . . .

3. U.S. Immigration and
Customs Enforcement
(I.C.E.) . . . . . . . . . . . . . . .

2. Sentenced inmates. . . . . .

4. Bureau of Indian Affairs .
5. Other – Specify

b. Unconvicted . . . . . . . . . . .
How many were —

b. State prison authorities

1. Awaiting trial/
arraignment. . . . . . . . . . .

1. For your state . . . . . . . . .

2. Awaiting transfer/hold
for other authorities. . . . . .

2. For other states . . . . . . .
c. Other local jail jurisdictions

3. Other . . . . . . . . . . . . . . .

• EXCLUDE inmates being housed for your own
jurisdiction (i.e., your own county/city inmates).

c. TOTAL (Sum of items II.3a
and II.3b should equal item I.1a)

1. Within your state
II.4. On June 30, 2014, how many persons
CONFINED in your jail facilities were —

2. Outside your state

not of Hispanic origin. . . . . . . .

II.6. a. During the 30-DAY period from June 1 to
June 30, 2014, on what day did your facility
hold the greatest number of inmates?

c. Hispanic or Latino . . . . . . .

• Peak population should be equal to or greater than
the confined inmate population reported in item I.1a.

d. American Indian/Alaska
Native, not of Hispanic origin .

June
e. Asian, not of Hispanic origin

....

d. TOTAL (Sum of items II.5a
to II.5c) . . . . . . . . . . . . . . . . .

a. White, not of Hispanic
origin . . . . . . . . . . . . . . . . . .
b. Black or African American,

.....

, 2014

b. How many persons were CONFINED on
that day?

f. Native Hawaiian or Other
Pacific Islander, not of
Hispanic origin . . . . . . . . . . . .

Number that day

g. Two or more races, not
of Hispanic origin . . . . . . . . .
h. Additional categories in your
information system — Specify

i. Not known . . . . . . . . . . . . .
j. TOTAL (Sum of items II.4a
to II.4i should equal item I.1a) . .

Page 3

FORM CJ-5D (3-7-2014)

II.7. Between July 1, 2013, and June 30, 2014,
what was the average daily population of all
jail confinement facilities operated by your
jurisdiction?

II.10. During the WEEK of June 24 to June 30, 2014,
how many persons discharged from your jail
jurisdiction were confined —
• Report time served, not sentence length, for
discharged person.

• Include inmates who participated in weekend
programs that allow offenders to serve their
sentences of confinement only on weekends
(e.g., Friday-Sunday).

Convicted Unconvicted
a. Less than 1 day

• To calculate the average daily population, add the
number of persons for each day during the period
July 1, 2013, through June 30, 2014, and divide
the result by 365.

b. 1 to 2 days . . . . . .
c. 3 to 7 days . . . . . .

Average daily population

d. 8 to 30 days . . . . .

II.8. On June 30, 2014, what was the total jail
capacity of your jail facilities?

e. 31 to 180 days . . .

a. Rated capacity
(The maximum number of beds
or inmates assigned by a rating
official to a facility, excluding
separate temporary holding
areas.) . . . . . . . . . . . . . . . .

f. More than 180 days
g. TOTAL (Sum of items
II.10a to II.10f should
equal item II.9b) . . .

Section III — POPULATION SUPERVISED
IN THE COMMUNITY
If item I.1b equals 0 (zero), SKIP to item IV.1

c. Design capacity
(The number of inmate’s
planners or architects intended
for all jail facilities in your
jurisdiction.) . . . . . . . . . . . . .

III.1. On June 30, 2014, how many persons under
your jail supervision who were NOT CONFINED,
participated in —
• EXCLUDE inmates on weekend programs.

II.9. During the WEEK of June 24 to June 30, 2014,
how many persons were —

a. Electronic monitoring . .
b. Home detention without
electronic monitoring. . .

c. Community service . . . .
d. Day reporting . . . . . . . . .
e. Other pretrial supervision
f. Other alternative work
programs . . . . . . . . . . .
• EXCLUDE inmates participating in work release
programs who return to the jail at night.

b. Final discharges from your jail facilities?
• INCLUDE all persons released after a period of
confinement (e.g., sentence completion, bail/bond
releases, other pretrial releases, transfers to other
jurisdictions, and deaths).
• INCLUDE those persons completing their weekend
sentence leaving the facility for the last time.
• EXCLUDE temporary discharges (e.g., work
releases, medical appointments/treatment, to courts,
furloughs, day reporters, and transfers to other
facilities within your jurisdiction).

g. Alcohol/drug treatment
programs . . . . . . . . . . .
• EXCLUDE inmates participating in alcohol/drug
treatment programs who are confined in the jail.
h. Other programs outside
of jail facilities – Specify

i. TOTAL (Sum of items III.1a to
III.1h should equal item I.1b) .

Final discharges

Page 4

FORM CJ-5D (3-7-2014)

III.2. On June 30, 2014, how many persons under
your jail supervision who were NOT
CONFINED were —
a. Adult males (age 18 or
older) . . . . . . . . . . . . . . . .

IV.2. During the 365-DAY period from July 1, 2013 to
June 30, 2014, were there any inmate-inflicted
physical or sexual assaults on facility staff in
your jail jurisdiction?
• Report any assaults that involved a weapon or
serious injury requiring immediate medical attention
more extensive than first aid.

b. Adult females (age 18 or
older) . . . . . . . . . . . . . . . .
c. Males under age 18

Yes –
Number of assaults on –

....

a. Correctional Officers . . . .
d. Females under age 18

..
b. All other staff . . . . . . . . .

e. TOTAL (Sum of items III.2a to
III.2d should equal item I.1b) .
2
III.3. Of all persons under your jail supervision who
were NOT CONFINED on June 30, 2014, how
many were —

No assaults

IV.3. During the 365-DAY period from July 1, 2013 to
June 30, 2014, were there any staff deaths as a
result of assaults by inmates?

a. Convicted . . . . . . . . . . . . .
1
b. Unconvicted . . . . . . . . . . .

Yes –
Number of deaths –

c. TOTAL (Sum of items III.3a and
III.3b should equal item I.1b) . .

a. Correctional Officer deaths
inflicted by inmates . . . . .
b. All other staff deaths
inflicted by inmates . . . . .

Section IV — STAFF SAFETY AND SECURITY
IV.1. On June 30, 2014, how many staff employed
by your jail jurisdiction were —
• Count each employee only once. Classify
employees with multiple functions by the function
performed most frequently.

No deaths

IV.4. During the 365-DAY period from July 1, 2013 to
June 30, 2014, how many persons CONFINED in
your jail jurisdiction were written up or found
guilty of —
a. Physical assault on
another inmate . . . . . . . . .

• INCLUDE only payroll and nonpayroll staff.

b. A drug violation, such
as use, possession,
or dealing drugs . . . . . . . .

• EXCLUDE staff paid through contractual
agreements and community volunteers.
a. Correctional Officers
(Deputies, monitors, and other
custody staff who spend more
than 50% of their time with the
incarcerated population.) . . . .

c. An alcohol violation,
including unauthorized
possession, use, or sale .
d. Possession of a weapon . .

b. All other staff
(Administrators, clerical and
maintenance staff, educational
staff, professional and technical
staff, and other staff
unspecified.) . . . . . . . . . . . .

e. Possession of stolen
property. . . . . . . . . . . . . . .
f. Escape or attempted
escape. . . . . . . . . . . . . . . .
g. Any other major
violation, including work
slowdowns, food strikes,
setting fire, rioting, etc. .

c. Total (sum of items
IV.1a and IV.1b) . . . . . . . . .

Page 5

CJ-5DA

OMB No. 1121-0094: Approval Expires 5/31/2016

CJ-5DA

RETURN
TO

U.S. Census Bureau
Governments Division
Washington, DC 20233-6800

U.S. DEPARTMENT OF JUSTICE

FORM
(3-7-2014)

2014 ANNUAL
SURVEY OF JAILS
MULTI-JURISDICTION OR PRIVATE

BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

U.S. DEPARTMENT OF COMMERCE
ECONOMICS AND STATISTICS ADMINISTRATION
U.S. CENSUS BUREAU
FACILITY

DATA SUPPLIED BY
Name
OFFICIAL
ADDRESS
TELEPHONE

Title
Number and street or P.O. box/Route number

City

Area Code

FAX
NUMBER

Number

Extension

State
Area Code

ZIP Code

Number

E-MAIL
ADDRESS

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What types of facilities are included in this survey?
Multi-Jurisdiction facilities and privately operated facilities in jurisdictions included with certainty in the Annual Survey of
Jails. These facilities are intended for adults but sometimes hold juveniles.
For Multi-Jurisdiction facility
Confinement facilities including detention centers, jails, and other correctional facilities administered by two or more
governments (or a board composed of representatives from two or more governments) included with certainty in the Annual
Survey of Jails.
• INCLUDE regional jails or city/county correctional centers.
• INCLUDE special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
• INCLUDE inmates held for jurisdictions, other than the participating jurisdictions.
For Privately Operated facility
Privately owned or operated confinement facilities in jurisdictions included with certainty in the Annual Survey of
Jails, including detention centers, jails, and other correctional facilities.
• INCLUDE temporary holding or lockup facilities if they are part of your combined function.
• EXCLUDE temporary holding or lockup facilities that are not part of your combined function from which inmates are
usually transferred within 72 hours and not held beyond arraignment. If your only function is a temporary holding or
lockup facility, DO NOT complete this form – contact Leslie Miller at 1–800–253–2078.
Certainty facilities
• INCLUDE private facilities in jail jurisdictions that held juvenile inmates at the time of the 2005 Census of Jail Inmates and
had an average daily population of 500 or more inmates during the 12 months ending June 30, 2005.
• INCLUDE private facilities in jail jusridictions that held only adult inmates and had an average daily population of 750
or more at the time of the 2005 Census of Jail Inmates.
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 2 hours 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.

FORM CJ-5DA (3-7-2014)

Section I — SUPERVISED POPULATION
I.1. On June 30, 2014, how many persons under the
supervision of your jail were —

I.2. Of all persons under your jail supervision
reported in item I.1c, how many were not U.S.
citizens?
Non-US citizens

a. CONFINED in your jail facility?
• INCLUDE persons on transfer to treatment facilities
but who remain under your jurisdiction.
• INCLUDE persons held for jurisdictions other than
the participating jurisdictions.

I.3. On the weekend prior to June 30, 2014, did
your jail facility have a weekend program?
• Weekend programs allow offenders to serve
their sentences of confinement only on
weekends (e.g., Friday — Sunday).

• INCLUDE persons in community-based programs
(e.g., work release, day release, drug/alcohol
treatment) who return to jail at night.

1
2

Yes — How many inmates
participated?
No

• EXCLUDE inmates on AWOL, escape, or
long-term transfer to other jurisdictions.
• EXCLUDE inmates being boarded out to
another county or held in another facility not
operated by your jail jurisdiction.

Section II — INMATE COUNTS AND MOVEMENTS
OF THE CONFINED POPULATION
II.1. On June 30, 2014, how many persons
CONFINED in your jail facility were —
a. Adult males (age 18 or
older) . . . . . . . . . . . . . . . . . . .

b. Under jail supervision but NOT CONFINED?

b. Adult females (age 18 or
older). . . . . . . . . . . . . . . . . . .

• INCLUDE all persons in community-based
programs run by your jail (e.g., electronic
monitoring, house arrest, community service, day
reporting, and work programs).

c. Males under age 18. . . . . . .

• EXCLUDE persons on pretrial release who are
not in a community based program run by your
jail.
• EXCLUDE persons under supervision of
probation, parole or other agencies.
• EXCLUDE inmates on weekend programs.
Weekend programs allow offenders to serve
their sentences of confinement only on
weekends (e.g., Friday — Sunday).

d. Females under age 18. . . . .
e. TOTAL (Sum of items II.1a to
II.1d should equal item I.1a). . .
II.2. Of all persons under the age of 18
CONFINED in your jail facility on June 30,
2014 (items II.1c and II.1d), how many were
tried, or awaiting trial, in adult court?
Number of persons under
age 18 held as adults. . . . . . . . . .

• EXCLUDE inmates participating in work release
programs who return to the jail at night.

c. TOTAL (Sum of items
I.1a and I.1b). . . . . . . . . . . . . .

Page 2

FORM CJ-5DA (3-7-2014)

II.3. Of all persons CONFINED in your jail facility
on June 30, 2014, how many were —

II.5. On June 30, 2014, how many persons
CONFINED in your jail facility were held for —
• For persons with a multiple hold, count them only
once with priority being Federal, State, and local.

• For persons with more than one status, report the
status with the most serious offense.
• For convicted inmates include probation and parole
violators with no new sentence.

a. Federal authorities
1. U.S. Marshals Service . .

a. Convicted. . . . . . . . . . . . .
2. Federal Bureau of Prisons
How many were —
1. Unsentenced inmates
or awaiting sentencing. . . .

3. U.S. Immigration and
Customs Enforcement
(I.C.E.) . . . . . . . . . . . . . . .

2. Sentenced inmates . . . . . .

4. Bureau of Indian Affairs .
5. Other – Specify

b. Unconvicted. . . . . . . . . . .
How many were —

b. State prison authorities

1. Awaiting trial/
arraignment. . . . . . . . . . .

1. For your state . . . . . . . . .

2. Awaiting transfer/hold
for other authorities. . . . . .

2. For other states . . . . . . .
c. Other local jail jurisdictions

3. Other . . . . . . . . . . . . . . .

• EXCLUDE inmates being housed for your own
jurisdiction (i.e., your own county/city inmates).

c. TOTAL (Sum of items II.3a
and II.3b should equal item I.1a)

1. Within your state . . . . . .
II.4. On June 30, 2014, how many persons
CONFINED in your jail facility were —

2. Outside your state

d. TOTAL (Sum of items II.5a
to II.5c) . . . . . . . . . . . . . . . . .

a. White, not of Hispanic
origin . . . . . . . . . . . . . . . . .
b. Black or African American,

not of Hispanic origin . . . . . . .

....

II.6. a. During the 30-DAY period from June 1 to
June 30, 2014, on what day did your facility
hold the greatest number of inmates?

c. Hispanic or Latino . . . . . .

• Peak population should be equal to or greater than
the confined inmate population reported in item I.1a.

d. American Indian/Alaska
Native, not of Hispanic origin

June
e. Asian, not of Hispanic origin

, 2014

b. How many persons were CONFINED on
that day?

f. Native Hawaiian or Other
Pacific Islander, not of
Hispanic origin . . . . . . . . . . .

Number that day

g. Two or more races, not
of Hispanic origin . . . . . . . .
h. Additional categories in your
information system — Specify

i. Not known . . . . . . . . . . . .
j. TOTAL (Sum of items II.4a
to II.4i should equal item I.1a) .

Page 3

FORM CJ-5DA (3-7-2014)

II.7. Between July 1, 2013, and June 30, 2014,
what was the average daily population
confined in your facility?

II.10. During the WEEK of June 24 to June 30, 2014,
how many persons discharged from your jail
facility were confined —
• Report time served, not sentence length, for
discharged person.

• Include inmates who participated in weekend
programs that allow offenders to serve their
sentences of confinement only on weekends
(e.g., Friday-Sunday).

Convicted

• To calculate the average daily population, add the
number of persons for each day during the period
July 1, 2013, through June 30, 2014, and divide
the result by 365.

Unconvicted

a. Less than 1 day. . .
b. 1 to 2 days. . . . . . .

Average daily population

c. 3 to 7 days. . . . . . .

II.8. On June 30, 2014, what was the total jail
capacity of your jail facility?

d. 8 to 30 days. . . . . .
e. 31 to 180 days. . . .

a. Rated capacity
(The maximum number of beds
or inmates assigned by a rating
official to a facility, excluding
separate temporary holding
areas.) . . . . . . . . . . . . . . . . .

f. More than 180 days.
g.TOTAL (Sum of items
II.10a to II.10f should
equal item II.9b). . . . . .

Section III — POPULATION SUPERVISED
IN THE COMMUNITY
If item I.1b equals 0 (zero), SKIP to item IV.1

c. Design capacity
(The number of inmate’s
planners or architects intended
for all jail facilities in your
jurisdiction.) . . . . . . . . . . . . .

III.1. On June 30, 2014, how many persons under
your jail supervision who were NOT CONFINED,
participated in —
• EXCLUDE inmates on weekend programs.

II.9. During the WEEK of June 24 to June 30, 2014,
how many persons were —

a. Electronic monitoring. . .
b. Home detention without
electronic monitoring. . . .

a. New admissions to your jail facility?
• INCLUDE persons officially booked into and housed
in your facility by formal legal document and by the
authority of the courts or some other official agency.
• INCLUDE those persons serving a weekend
sentence coming into the facility for the first time.
• EXCLUDE returns from escape, work release,
medical appointments/treatment facilities, bail and
court appearances.
New admissions

c. Community service. . . . .
d. Day reporting. . . . . . . . . .
e. Other pretrial supervision.
f. Other alternative work
programs. . . . . . . . . . . . .
• EXCLUDE inmates participating in work release
programs who return to the jail at night.

b. Final discharges from your jail facility?
• INCLUDE all persons released after a period of
confinement (e.g., sentence completion, bail/bond
releases, other pretrial releases, transfers to other
jurisdictions, and deaths).
• INCLUDE those persons completing their weekend
sentence leaving the facility for the last time.
• EXCLUDE temporary discharges (e.g., work
releases, medical appointments/treatment, to courts,
furloughs, day reporters, and transfers to other
facilities within your jurisdiction).

g. Alcohol/drug treatment
programs. . . . . . . . . . . . .
• EXCLUDE inmates participating in alcohol/drug
treatment programs who are confined in the jail.
h. Other programs outside
of jail facilities – Specify

i. TOTAL (Sum of items III.1a to
III.1h should equal item I.1b). .

Final discharges

Page 4

FORM CJ-5DA (3-7-2014)

III.2. On June 30, 2014, how many persons under
your jail supervision who were NOT CONFINED
were —
a. Adult males (age 18 or
older) . . . . . . . . . . . . . . . . .

IV.2. During the 365-DAY period from July 1, 2013 to
June 30, 2014, were there any inmate-inflicted
physical or sexual assaults on facility staff in
your jail?
• Report any assaults that involved a weapon or
serious injury requiring immediate medical attention
more extensive than first aid.

b. Adult females (age 18 or
older) . . . . . . . . . . . . . . . . .

Yes –
Number of assaults on —

c. Males under age 18. . . . . .

a. Correctional Officers. . . . .
d. Females under age 18. . . .
b. All other staff . . . . . . . . .

e. TOTAL (Sum of items III.2a to
III.2d should equal item I.1b). . .
2
III.3. Of all persons under your jail supervision who
were NOT CONFINED on June 30, 2014, how
many were —

No assaults

IV.3. During the 365-DAY period from July 1, 2013 to
June 30, 2014, were there any staff deaths as a
result of assaults by inmates?

a. Convicted. . . . . . . . . . . . .
1
b. Unconvicted. . . . . . . . . . .

Yes –
Number of deaths —

c. TOTAL (Sum of items III.3a and
III.3b should equal item I.1b) .

a. Correctional Officer deaths
inflicted by inmates . . . . .
b. All other staff deaths
inflicted by inmates . . . . .

Section IV — STAFF SAFETY AND SECURITY
IV.1. On June 30, 2014, how many staff employed
by your jail were —
• Count each employee only once. Classify
employees with multiple functions by the function
performed most frequently.

No deaths

IV.4. During the 365-DAY period from July 1, 2013 to
June 30, 2014, how many persons CONFINED in
your jail were written up or found guilty of —
a. Physical assault on
another inmate. . . . . . . . .

• INCLUDE only payroll and nonpayroll staff.

b. A drug violation, such
as use, possession,
or dealing drugs. . . . . . . . .

c. An alcohol violation,
including unauthorized
possession, use, or sale. .
d. Possession of a weapon. . .

b. All other staff
(Administrators, clerical and
maintenance staff, educational
staff, professional and technical
staff, and other staff
unspecified.) . . . . . . . . . . . . .

c. Total (sum of items
IV.1a and IV.1b) . . . . . . . . . . .