CJ-11A Arrest-related Death Incident Report for Law Enforcement

Attachment C:
Form CJ-11A: Arrest-related Death Incident
Report for Law Enforcement Agencies

Bureau of Justice Statistics

Arrest-related Deaths Program—2015 Pilot Study
The Death in Custody Reporting Act (DICRA) of 2013 (P.L. 113-242) requires any state receiving funds from the
Department of Justice to report information on a quarterly basis regarding the death of any person who is detained,
under arrest, or in the process of being arrested, en route to be incarcerated, or incarcerated.
In response to these reporting requirements, BJS is conducting a pilot study to determine the most efficient and
comprehensive means of identifying arrest-delated deaths and collecting information about individuals who die in the
custody of law enforcement and the circumstances surrounding those deaths. Through review of open sources,
including news outlets, official agency documents, and other publicly-available information, BJS has compiled a
preliminary list of arrest-related deaths that occurred between June 1 and August 31, 2015.
BJS is now conducting a survey of law enforcement agencies and medical examiner/ coroner’s offices with jurisdiction in
one or more of the deaths identified through open source review. The survey is designed to (1) confirm whether the
incident meets the definition of an arrest-related death and other inclusionary criteria, (2) identify any additional arrestrelated deaths that BJS did not identify during its open source review, and (3) for all identified arrest-related deaths,
collect additional information about the decedent and the circumstances surrounding the incident.
For the purposes of the ARD program, a death is “arrest-related” when the event causing the death (e.g., gunshot
wound, self-inflicted injury, cardiac arrest, fall from a height, drowning, etc.) occurs during an interaction with state or
local law enforcement personnel. Please exclude any deaths that occurred while the decedent was incarcerated in a jail
or prison, or any deaths where the decedent was in the custody of federal or tribal law enforcement agencies.
Deaths reportable to the ARD program include:






All deaths attributed to any use of force by law enforcement personnel (e.g., officer-involved shootings,
accidental deaths caused by weapons or tactics)
Any death that occurs while the decedent’s freedom to leave is restricted by state or local law enforcement
prior to, during, or following an arrest:
o While detained for questioning or investigation (i.e., Terry stop)
o During the process of apprehension (i.e., pursuit of criminal suspect, standoff with law enforcement)
o While in the custody of, or shortly after restraint by, law enforcement (even if the decedent was not
formally under arrest)
o During transport to or from law enforcement or medical facilities
While confined in lockups or booking centers (i.e., facilities from which arrestees are usually transferred within
72 hours and not held beyond arraignment)
Any death that occurs during an interaction with law enforcement personnel during response to medical or
mental health assistance (e.g., response to suicidal persons).

Form CJ-11, Arrest-Related Deaths Quarterly Summary, identifies each arrest-related death occurring in your jurisdiction
from June 1, 2015 through August 31, 2015. Form CJ-11A, Arrest-Related Death Incident Report, collects information on
decedent characteristics and circumstances surrounding the death for each arrest-related death identified on Form CJ11, Arrest-Related Deaths Quarterly Summary.
If you have any questions about this form or the Arrest-related Deaths Program – 2015 Pilot Study, please contact:
Michael Planty
Victimization Unit Chief
Bureau of Justice Statistics
(202) 514-9746
Michael.Planty@usdoj.gov

OR

Duren Banks
ARD Program Manager
RTI International
(919) 541-8026
durenbanks@rti.org

Arrest-related Deaths Program—2015 Pilot Study

FORM CJ-11A

Arrest-Related Death Incident Report

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

Doe, John A.

June 2, 2015

2:20 PM

1. Where did the event causing the death occur?
Street Address:
___________________________________
City, State, Zip:
___________________________________

7. What was the reason for the initial contact
between the decedent and law enforcement
personnel? (Mark only one)
 Civilian request for response to criminal or
suspicious activity, specify reason for request:
_______________________________________

2. What location category best describes where the
event causing the death occurred? (Mark only one)
 Residence/home
 Law enforcement facility
 Business, specify type:
_________________________
 Roadway/highway/street/sidewalk
 Parking lot/garage
 Field/woods/lake/waterway/beach
 Other, specify:
__________________________________
3. What was the decedent’s sex?
 Male
 Female
4. What was the decedent’s date of birth (DOB)?
____/____/____ or age at death if DOB unknown _____
5. What was the decedent’s ethnic origin? (Mark only
one)
 Hispanic or Latino
 Not Hispanic or Latino
 Unknown
6. What was the decedent’s race? (Mark all that
apply)
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Other
 Unknown

 Civilian request for medical, mental health, or
welfare assistance, specify reason for request:
_______________________________________

 Routine patrol/on-view (other than traffic stop),
specify observed behavior:
_______________________________________

 Traffic/vehicle stop, specify reason for stop:
_______________________________________

 Warrant service, specify charge:
_______________________________________

 Other reason for contact, specify reason:
_______________________________________

 Unknown
8. Did the deceased commit or allegedly commit any
criminal events in the events leading up to the
death?
 Yes
 No – medical/mental health assistance call
 No –other; specify:___________________
9. What were the most serious reported offenses
committed by the deceased?
01___________________________________
02___________________________________
03___________________________________
10. At any time during the incident, did the decedent:
(Mark all that apply)
 Barricade self or initiate standoff
 Verbally threaten other(s)
 Resist being handcuffed or arrested
 Attempt to escape/flee from custody
 Attempt to physically assault officer(s)
 Attempt to gain possession of officer’s weapon
 Gain possession of officer’s weapon
 Escape/flee from custody
 None of the above
 Unknown

11. At any time during the incident, did the decedent:
(Mark all that apply)
 Make suicidal statements?
 Appear to be intoxicated (either alcohol or
drugs)?
 Exhibit any mental health problems
OR
 Unknown
 None of the above
12. At any time during the incident did the decedent
have a weapon or appear to have a weapon?
 Yes
If so, did the decedent do any of the following?
(Mark all that apply)
 Displayed firearm without discharge
 Discharged firearm
 Displayed other weapon, specify weapon
displayed (e.g., sharp object, blunt
instrument, toy weapon):
________________________________
 Used other weapon, specify weapon used
(e.g., sharp object, blunt instrument, toy
weapon)::
________________________________
 Used vehicle as a weapon
 No
 Unknown
 No
 Unknown
13. At any time during the incident, did the decedent
attempt to injure officers or injure others?
 Yes, mark all that apply:
 Killed law enforcement personnel
 Injured law enforcement personnel
 Attempted to injure law enforcement
personnel
 Killed civilian(s)
 Injured civilian(s)
 Attempted to injure civilian(s)
 No
 Unknown

14. At any time during the incident, did law
enforcement personnel:
YES

NO

UNKNOWN

Fight or struggle with decedent?
Physically restrain decedent
(e.g., control hold, body
compression)?
Restrain decedent with
equipment (e.g., handcuffs, leg
shackles)?
Place decedent in prone
position?
Engage in motor vehicle pursuit?
Engage in foot pursuit?
Arrest the decedent?
15. At any time during the incident, did law
enforcement personnel use any of the following
weapons?
 Yes, mark all that apply:
 Firearm discharge
 Conducted energy device (Taser)
contact
 Explosive device
 Pepper/OC spray, mace dispersion
 Baton/blunt instrument impact
 Hands/ feet/ fist
 Other, specify: __________________
 No
 Unknown
16. If law enforcement personnel discharged a firearm
during this arrest process, approximately how
many shots were fired?
 0-3
 4-6
 7-10
 10+
17. Did any other law enforcement agencies respond
to calls for service related to this incident?
 Yes
 No
18. Please indicate or estimate how many officers
(from all involved law enforcement agencies)
responded to the initial call for service: _______

Notes: