CJ-12s Arrest-related Deaths Quarterly Summary (sample) for Med

Attachment E:
Form CJ-12s: Arrest-related Deaths Quarterly
Summary (sample) for Medical Examiner/
Coroner’s Offices

Bureau of Justice Statistics

Arrest-related Deaths Program—2015 Pilot Study
The Death in Custody Reporting Act (DICRA) of 2013 (P.L. 113-242) encourages states 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 this legislation, 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.
In addition to identifying arrest-related deaths through open source review, we are also contacting a random sample of
medical examiner/ coroner’s offices to determine whether there have been any arrest-related deaths in those
jurisdictions between June 1 and August 31, 2015. This survey asks you to identify any deaths that occurred during an
interaction state or local law enforcement personnel during this time period. For those deaths, we request that you
provide information about the decedent, cause of death, and manner of death.
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 homicides due to legal intervention or deaths attributed to any use of force by law enforcement personnel
(e.g., officer-involved shootings, accidental deaths caused by weapons or tactics)
All manners of death, including those resulting from homicides, suicides, natural causes, accidents, that occur
while the decedent’s freedom to leave is restricted by state or local law enforcement prior to, during, or
following an arrest, including confinements 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 state or local law enforcement personnel during response to
medical or mental health assistance (e.g., response to suicidal persons)

Form CJ-12s, Arrest-Related Deaths Quarterly Summary (sample), asks agencies to identify any arrest-related death
occurring in your jurisdiction from June 1, 2015 through August 31, 2015. Form CJ-12A, Arrest-Related Death Incident
Report, collects information on decedent characteristics and circumstances surrounding the death for each arrestrelated death identified on Form CJ-12s, Arrest-Related Deaths Quarterly Summary (sample).
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-12s

Arrest-Related Deaths Quarterly Summary (sample)

Please identify any arrest-related deaths occurring in your jurisdiction from June 1, 2015 through August 31, 2015,
including decedent name, date of death, and time of death; and then proceed to Form CJ-12A to complete additional
information about the decedent and the circumstances surrounding the death.
Medical examiner/ Coroner’s office name

Name of jurisdiction served

Did your agency provide death certificates for any deaths classified as homicides due to legal intervention between
June 1 and August 31, 2015?
 Yes [list below]
 No
 My organization has no means to classify homicides due to legal
intervention.
Decedent name (Last, First, Middle Initial)
Date of Death
Time of Death

1
2

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

3

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

Did your agency provide death certificates for any other deaths that may defined as arrest-related between June 1
and August 31, 2015?

 Yes [list below]

 No

 My organization has no means to track whether a death is arrestrelated.

4

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

5

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death

6

Decedent name (Last, First, Middle Initial)

Date of Death

Time of Death