CJ-12A Arrest-related Death Incident Report for Medical Examine

Attachment F:
Form CJ-12A: Arrest-related Death Incident
Report 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) 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 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-12, Arrest-Related Deaths Quarterly Summary, identifies each 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 arrest-related death identified on Form CJ12, 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

Bureau of Justice Statistics

Arrest-related Deaths Program—2015 Pilot Study

FORM CJ-12A

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. What was the decedent’s sex?
 Male
 Female
2. What was the decedent’s date of birth (DOB)?
____/____/____ or age at death if DOB unknown _____
3. What was the decedent’s ethnic origin? (Mark only
one)
 Hispanic or Latino
 Not Hispanic or Latino
 Unknown
4. 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
5. If a weapon caused the death, what type of
weapon caused the death (Mark only one)
 Handgun
 Rifle/ shotgun
 Firearm, unspecified
 Conducted energy device (e.g., Taser)
 Knife/ edged instrument
 Baton, blunt instrument
 Other, specify:________________________
 Vehicle-involved death (e.g., vehicle accident)
 Not applicable, weapon or vehicle did not cause
death
 Unknown

Notes:

6. Where did the death occur? (Mark only one)
 Law enforcement facility/ booking center
 Scene of incident
 During transport to a medical facility
 During transport to a law enforcement facility
 Medical facility following clinical intervention
 Other, specify:________________________
 Unknown
7. What was the manner of death? (Mark only one)
 Natural
 Homicide
If so, Was the death classified as due to legal
intervention?
 Yes
 No
 Accident
 Suicide
 Could not be determined
 Unknown
8. What was cause of death?
Immediate cause:
________________________________
Secondary cause (if known):
________________________________
 Unknown
9. Did the autopsy report or medical evaluation
indicate the presence of alcohol or other Schedule
I or II controlled substances?
 Yes: mark all that apply:
 Alcohol
 Schedule I or Schedule II controlled
substances; specify:
______________________________
 No
 Could not determine
 N/A, did not obtain autopsy report or medical
evaluation