State Correction Incident Report

DEATH IN CUSTODY REPORTING ACT
Fiscal Year 20XX

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE ASSISTANCE
ACTING AS COLLECTION AGENT:
***

FORM DCR-1A
For each reportable death identified in your Quarterly Summary, please respond to all of the following questions regarding
the decedent’s characteristics and the circumstances surrounding the death. Information provided on this form must have
originated from official government records, documents, or personnel. You will not be able to SAVE the information
unless all fields are completed.
For directions on how to complete this form, please refer to the “Instructions for Completion.”

DATA SUPPLIED BY:
Name:

Email:

Title:

Telephone:

(__ __ __) __ __ __ - __ __ __ __

Agency:

Fax:

(__ __ __) __ __ __ - __ __ __ __

State:

Date:

Decedent Name (Last, First, Middle Initial)

Date of Death

Time of Death

Location of Event Causing the Death (Street Address, City, State, Zip)

1.

2.

3.

4.

What was the decedent’s sex?



Male



Female

5.

What location category best describes where the
event causing the death occurred? (Mark only one)



Residence/home



Law enforcement facility

What was the decedent’s date of birth (or approximate
age at death if DOB is unknown)?



Business – please specify type: _______________

____________________________________________



Other – please specify: _____________________





Unknown

Unknown

What was the decedent’s ethnic origin? (Mark only
one)



Hispanic or Latino



Not Hispanic or Latino



Unknown

6.

Law enforcement agency that detained, arrested, or
was in the process of arresting the deceased:
______________________________________________

7.

What was the decedent’s race? (Mark all that apply)

Facility Type (if applicable):



Municipal or County Jail



State Prison



American Indian or Alaska Native



State-Run Boot Camp Prison



Asian



Contracted Boot Camp Prison



Black or African American



Any State or Local Contract Facility



Native Hawaiian or Other Pacific Islander



Other Local or State Correctional Facility (to include
any juvenile facilities)



White



Other



Unknown

OMB number XXX-XXXX, expires on XX/XX/20XX

8.

Brief description of the circumstances surrounding
the death:



Natural causes



Other – please specify: _______________________

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