DCRP Appendix

Appendix C. Attachment Table of Contents
Attachment A.

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

p. 2-3

Attachment B.

2013 Death in Custody Reporting Act (P.L. 113-242)

p. 4-8

Attachment C.

42 USC 3732

p. 9-13

Attachment D.

42 USC 3739 (g)

p. 14-16

Attachment E.

Prison survey forms NPS-4 and NPS-4A

p. 17-22

Attachment F.

U.S. Standard Death Certificate

p. 23-27

Attachment G.

42 USC 3735

p. 28-29

Attachment H.

Mailing packet

p. 30-35

Attachment I.

Verification call script

p. 36-41

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.

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Attachment B. 2013 Death in Custody Report Act
(P.L. 113-242).

PUBLIC LAW 113–242—DEC. 18, 2014

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DEATH IN CUSTODY REPORTING ACT OF 2013

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128 STAT. 2860

PUBLIC LAW 113–242—DEC. 18, 2014

Public Law 113–242
113th Congress
An Act
Dec. 18, 2014
[H.R. 1447]

Death in Custody
Reporting Act
of 2013.
42 USC 13701
note.
42 USC 13727.

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Waiver authority.

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To encourage States to report to the Attorney General certain information regarding
the deaths of individuals in the custody of law enforcement agencies, and for
other purposes.

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 2013’’.
SEC. 2. STATE INFORMATION REGARDING INDIVIDUALS WHO DIE IN
THE CUSTODY OF LAW ENFORCEMENT.

(a) IN GENERAL.—For each fiscal year after the expiration of
the period specified in subsection (c)(1) in which a State receives
funds for a program referred to in subsection (c)(2), the State
shall report to the Attorney General, on a quarterly basis and
pursuant to guidelines established by the Attorney General,
information regarding the death of any person who is detained,
under arrest, or is in the process of being arrested, is en route
to be incarcerated, or is incarcerated at a municipal or county
jail, State prison, State-run boot camp prison, boot camp prison
that is contracted out by the State, any State or local contract
facility, or other local or State correctional facility (including any
juvenile facility).
(b) INFORMATION REQUIRED.—The report required by this section shall contain information that, at a minimum, includes—
(1) the name, gender, race, ethnicity, and age of the
deceased;
(2) the date, time, and location of death;
(3) the law enforcement agency that detained, arrested,
or was in the process of arresting the deceased; and
(4) a brief description of the circumstances surrounding
the death.
(c) COMPLIANCE AND INELIGIBILITY.—
(1) COMPLIANCE DATE.—Each State shall have not more
than 120 days from the date of enactment of this Act to comply
with subsection (a), except that—
(A) the Attorney General may grant an additional 120
days to a State that is making good faith efforts to comply
with such subsection; and
(B) the Attorney General shall waive the requirements
of subsection (a) if compliance with such subsection by
a State would be unconstitutional under the constitution
of such State.

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PUBLIC LAW 113–242—DEC. 18, 2014

128 STAT. 2861

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(2) INELIGIBILITY FOR FUNDS.—For any fiscal year after
the expiration of the period specified in paragraph (1), a State
that fails to comply with subsection (a), shall, at the discretion
of the Attorney General, be subject to not more than a 10percent reduction of the funds that would otherwise be allocated
for that fiscal year to the State under subpart 1 of part E
of title I of the Omnibus Crime Control and Safe Streets Act
of 1968 (42 U.S.C. 3750 et seq.), whether characterized as
the Edward Byrne Memorial State and Local Law Enforcement
Assistance Programs, the Local Government Law Enforcement
Block Grants Program, the Edward Byrne Memorial Justice
Assistance Grant Program, or otherwise.
(d) REALLOCATION.—Amounts not allocated under a program
referred to in subsection (c)(2) to a State for failure to fully comply
with subsection (a) shall be reallocated under that program to
States that have not failed to comply with such subsection.
(e) DEFINITIONS.—In this section the terms ‘‘boot camp prison’’
and ‘‘State’’ have the meaning given those terms, respectively, in
section 901(a) of the Omnibus Crime Control and Safe Streets
Act of 1968 (42 U.S.C. 3791(a)).
(f) STUDY AND REPORT OF INFORMATION RELATING TO DEATHS
IN CUSTODY.—
(1) STUDY REQUIRED.—The Attorney General shall carry
out a study of the information reported under subsection (b)
and section 3(a) to—
(A) determine means by which such information can
be used to reduce the number of such deaths; and
(B) examine the relationship, if any, between the
number of such deaths and the actions of management
of such jails, prisons, and other specified facilities relating
to such deaths.
(2) REPORT.—Not later than 2 years after the date of the
enactment of this Act, the Attorney General shall prepare and
submit to Congress a report that contains the findings of the
study required by paragraph (1).

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SEC. 3. FEDERAL LAW ENFORCEMENT DEATH IN CUSTODY REPORTING
REQUIREMENT.

42 USC 13727a.

(a) IN GENERAL.—For each fiscal year (beginning after the
date that is 120 days after the date of the enactment of this
Act), the head of each Federal law enforcement agency shall submit
to the Attorney General a report (in such form and manner specified
by the Attorney General) that contains information regarding the
death of any person who is—
(1) detained, under arrest, or is in the process of being
arrested by any officer of such Federal law enforcement agency
(or by any State or local law enforcement officer while participating in and for purposes of a Federal law enforcement operation, task force, or any other Federal law enforcement capacity
carried out by such Federal law enforcement agency); or
(2) en route to be incarcerated or detained, or is incarcerated or detained at—
(A) any facility (including any immigration or juvenile
facility) pursuant to a contract with such Federal law
enforcement agency;
(B) any State or local government facility used by
such Federal law enforcement agency; or

Effective date.

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128 STAT. 2862

PUBLIC LAW 113–242—DEC. 18, 2014

(C) any Federal correctional facility or Federal pretrial detention facility located within the United States.
(b) INFORMATION REQUIRED.—Each report required by this section shall include, at a minimum, the information required by
section 2(b).
(c) STUDY AND REPORT.—Information reported under subsection
(a) shall be analyzed and included in the study and report required
by section 2(f).

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Approved December 18, 2014.

LEGISLATIVE HISTORY—H.R. 1447:
HOUSE REPORTS: No. 113–285 (Comm. on the Judiciary).
CONGRESSIONAL RECORD:
Vol. 159 (2013): Dec. 12, considered and passed House.
Vol. 160 (2014): Dec. 10, considered and passed Senate.

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Attachment C. 42 USC § 3732

Attachment D. 42 USC § 3789(g)

Attachment E. Prison Survey forms NPS-4 and NPS-4A

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

DEATHS IN CUSTODY—2015
ANNUAL SUMMARY OF INMATE DEATHS
IN STATE PRISONS

Form NPS-4

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

What deaths should be reported?
INCLUDE deaths of ALL persons…


Confined in your correctional facilities, whether housed
under your jurisdiction or that of another state



Under your jurisdiction but housed in private correctional
facilities, whether located in or out of state



Under your jurisdiction but in special facilities (e.g.,
medical/ treatment/release centers, halfway houses,
police/court lockups, or work farms)



EXCLUDE deaths of ALL persons…


Executed in your state



Confined in local jail facilities, whether located in or out of
state



Under your jurisdiction but housed in a state-operated
correctional facility in another state or in a federal facility



Under probation or parole supervision in your state

In transit to or from your facilities while under your
supervision

During 2015, how many persons died while in the custody of your state correctional facilities?
Number of deaths in 2015
Please fill out the number of deaths that occurred in calendar year 2015 above and submit this form and corresponding NPS-4A forms
to RTI International. You may submit these data in one of these ways:
ONLINE: Complete this form online at: https://bjsdcrp.rti.org
E-MAIL: bjsdcrp@rti.org
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

For each inmate death, please ensure that you have submitted a STATE PRISON INMATE DEATH REPORT (NPS-4A) form.
IF NO DEATHS OCCURRED, it is still important that you complete this form and return it to RTI International.
If you need assistance, contact Matt Bensen of RTI International toll-free at (800) 344-1387 or send an e-mail to bjsdcrp@rti.org

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 5 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»

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

DEATHS IN CUSTODY—2016
STATE PRISON INMATE
DEATH REPORT

Form NPS-4A
(Addendum)

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 will 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

MAIL: RTI International, Attn: Data Capture
Project Number: 0215015.001.100.102.100
5265 Capital Boulevard
Raleigh, NC 27690-1652

E-MAIL: bjsdcrp@rti.org
FAX (TOLL-FREE): (866) 800-9179

If you need assistance, call Matt Bensen of RTI International toll-free at (800) 344-1387 or bjsdcrp@rti.org

What deaths should be reported?
INCLUDE deaths of ALL persons…






Confined in your correctional facilities, whether housed
under your jurisdiction or that of another state
Under your jurisdiction but housed in private correctional
facilities, whether located in or out of state
Under your jurisdiction but in special facilities (e.g.,
medical/treatment/release centers, halfway houses,
police/court lockups, or work farms)
In transit to or from your facilities while under your
supervision

EXCLUDE deaths of ALL persons…


Executed in your state



Confined in local jail facilities, whether located in or out of
state



Under your jurisdiction but housed in a state-operated
correctional facility in another state or in a federal facility



Under probation or parole supervision in your state



Under your jurisdiction but on AWOL or escape-status at
the time of death

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»

STATE PRISON INMATE DEATH REPORT
1.

8.

What was the inmate’s name?

LAST

FIRST

On what date was the inmate admitted to one of
your correctional facilities?

MI
MONTH

2.

DAY

YEAR

On what date did the inmate die?
2
MONTH

DAY

0

1

9.

6

For what offense(s) was the inmate being held?
a.

YEAR

b.
3.

What was the name and location of the
correctional facility involved?

c.
d.

Facility Name:

e.

Facility City:

Facility State:
10. Since admission, did the inmate ever stay
overnight in a mental health facility?

4.

What was the inmate’s date of birth?

MONTH

DAY

Yes
No
Don’t Know

YEAR

11. Where did the inmate die?
5.

What was the inmate’s sex?
Male
Female

6.

Was the inmate of Hispanic, Latino, or Spanish
origin?
Yes
No

In a general housing unit in the facility or in a
general housing unit on prison grounds
In a segregation unit
In a special medical unit/infirmary within your
facility
In a special mental health services unit within
your facility
In a medical center outside your facility
In a mental health center outside your facility
While in transit
Elsewhere
Please Specify:

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:

«AGENCY ID»

12. 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 Q13
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
13. What was the cause of death?

CONTINUE TO Q13

*** 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]

0

14. 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 prison facility or on the prison 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)
In a special medical unit/infirmary
[PLEASE
In a special mental health services unit
SPECIFY]
In a segregation unit
On death row, special unit awaiting capital punishment
Elsewhere within the prison facility
Please Specify:

Outside the prison facility (e.g., while on work release or on work detail)
Elsewhere
Please Specify:

15. 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)
«AGENCY ID»

16. 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
Evaluated 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 ...........................  ...............................

17. 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 F. U.S. Standard Death Certificate

U.S. STANDARD CERTIFICATE OF DEATH

4a. AGE-Last Birthday
(Years)

4b. UNDER 1 YEAR

4c. UNDER 1 DAY

Months

Hours

Days

7a. RESIDENCE-STATE

2. SEX

5. DATE OF BIRTH (Mo/Day/Yr) 6. BIRTHPLACE (City and State or Foreign Country)

7b. COUNTY

7c. CITY OR TOWN
7e. APT. NO.

8. EVER IN US ARMED FORCES?
□ Yes □ No

STATE FILE NO.
3. SOCIAL SECURITY NUMBER

Minutes

7d. STREET AND NUMBER

To Be Completed/ Verified By:
FUNERAL DIRECTOR:

NAME OF DECEDENT ____________________________________________
For use by physician or institution

LOCAL FILE NO.
1. DECEDENT’S LEGAL NAME (Include AKA’s if any) (First, Middle, Last)

7f. ZIP CODE

9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown

7g. INSIDE CITY LIMITS?

□ Yes □

No

10. SURVIVING SPOUSE’S NAME (If wife, give name prior to first marriage)

11. FATHER’S NAME (First, Middle, Last)

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

13a. INFORMANT’S NAME

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

13b. RELATIONSHIP TO DECEDENT

14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
15. FACILITY NAME (If not institution, give street & number)
18. METHOD OF DISPOSITION: □ Burial □ Cremation
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
20. LOCATION-CITY, TOWN, AND STATE

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:

□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):
16. CITY OR TOWN , STATE, AND ZIP CODE

17. COUNTY OF DEATH

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT

23. LICENSE NUMBER (Of Licensee)
24. DATE PRONOUNCED DEAD (Mo/Day/Yr)

ITEMS 24-28 MUST BE COMPLETED BY PERSON
WHO PRONOUNCES OR CERTIFIES DEATH

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
29. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)

25. TIME PRONOUNCED DEAD

27. LICENSE NUMBER

30. ACTUAL OR PRESUMED TIME OF DEATH

28. DATE SIGNED (Mo/Day/Yr)
31. WAS MEDICAL EXAMINER OR
CORONER CONTACTED? □ Yes

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition --------->
resulting in death)
Sequentially list conditions,
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

□ No

Approximate
interval:
Onset to death

CAUSE OF DEATH (See instructions and examples)

a._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

b._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

c._____________________________________________________________________________________________________________
Due to (or as a consequence of):

_____________

d._____________________________________________________________________________________________________________

_____________

To Be Completed By:
MEDICAL CERTIFIER

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

35.

DID TOBACCO USE CONTRIBUTE
TO DEATH?

□

Yes □ Probably

□

No

□

33. WAS AN AUTOPSY PERFORMED?
□ Yes □ No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? □ Yes □ No
37. MANNER OF DEATH

36. IF FEMALE:
□ Not pregnant within past year

□ Natural

□ Pregnant at time of death

□ Accident □ Pending Investigation

□ Not pregnant, but pregnant within 42 days of death

Unknown

□ Homicide

□ Suicide

□ Could not be determined

□ Not pregnant, but pregnant 43 days to 1 year before death
□ Unknown if pregnant within the past year
38. DATE OF INJURY
39. TIME OF INJURY
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
(Mo/Day/Yr) (Spell Month)
42. LOCATION OF INJURY:

State:

41. INJURY AT WORK?
□ Yes □ No

City or Town:

Street & Number:
43. DESCRIBE HOW INJURY OCCURRED:

Apartment No.:

Zip Code:
44. IF TRANSPORTATION INJURY, SPECIFY:
□ Driver/Operator
□ Passenger
□ Pedestrian
□ Other (Specify)

45. CERTIFIER (Check only one):
□ Certifying physician-To the best of my knowledge, death occurred due to the cause(s) and manner stated.
□ Pronouncing & Certifying physician-To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
□ Medical Examiner/Coroner-On the basis of examination, and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.
Signature of certifier:_____________________________________________________________________________
46. NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)

47. TITLE OF CERTIFIER

48. LICENSE NUMBER

To Be Completed By:
FUNERAL DIRECTOR

51. DECEDENT’S EDUCATION-Check the box
that best describes the highest degree or level of
school completed at the time of death.

49. DATE CERTIFIED (Mo/Day/Yr)

50. FOR REGISTRAR ONLY- DATE FILED (Mo/Day/Yr)

52. DECEDENT OF HISPANIC ORIGIN? Check the box
that best describes whether the decedent is
Spanish/Hispanic/Latino. Check the “No” box if
decedent is not Spanish/Hispanic/Latino.

53. DECEDENT’S RACE (Check one or more races to indicate what the
decedent considered himself or herself to be)

□

No, not Spanish/Hispanic/Latino

□

Yes, Mexican, Mexican American, Chicano

□
□
□
□
□
□
□
□
□
□
□
□

□

8th grade or less

□

9th - 12th grade; no diploma

□

High school graduate or GED completed

□

Some college credit, but no degree

□

Associate degree (e.g., AA, AS)

□

Yes, Puerto Rican

□

Bachelor’s degree (e.g., BA, AB, BS)

□

Yes, Cuban

□

Master’s degree (e.g., MA, MS, MEng,
MEd, MSW, MBA)

□

Yes, other Spanish/Hispanic/Latino
(Specify) __________________________

□

Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD, DDS,
DVM, LLB, JD)

□
□
□

White
Black or African American
American Indian or Alaska Native
(Name of the enrolled or principal tribe) _______________
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (Specify)__________________________________________
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (Specify)_________________________________
Other (Specify)___________________________________________

54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED).
55. KIND OF BUSINESS/INDUSTRY

REV. 11/2003

MEDICAL CERTIFIER INSTRUCTIONS for selected items on U.S. Standard Certificate of Death
(See Physicians’ Handbook or Medical Examiner/Coroner Handbook on Death Registration for instructions on all items)

ITEMS ON WHEN DEATH OCCURRED
Items 24-25 and 29-31 should always be completed. If the facility uses a separate pronouncer or other person to indicate that death has taken
place with another person more familiar with the case completing the remainder of the medical portion of the death certificate, the pronouncer
completes Items 24-28. If a certifier completes Items 24-25 as well as items 29-49, Items 26-28 may be left blank.

ITEMS 24-25, 29-30 – DATE AND TIME OF DEATH
Spell out the name of the month. If the exact date of death is unknown, enter the approximate date. If the date cannot be approximated, enter
the date the body is found and identify as date found. Date pronounced and actual date may be the same. Enter the exact hour and minutes
according to a 24-hour clock; estimates may be provided with “Approx.” placed before the time.

ITEM 32 – CAUSE OF DEATH (See attached examples)
Take care to make the entry legible. Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print
legibly using permanent black ink in completing the CAUSE OF DEATH Section. Do not abbreviate conditions entered in section.
Part I (Chain of events leading directly to death)
•Only one cause should be entered on each line. Line (a) MUST ALWAYS have an entry. DO NOT leave blank. Additional lines may be added
if necessary.
•If the condition on Line (a) resulted from an underlying condition, put the underlying condition on Line (b), and so on, until the full sequence is
reported. ALWAYS enter the underlying cause of death on the lowest used line in Part I.
•For each cause indicate the best estimate of the interval between the presumed onset and the date of death. The terms “unknown” or
“approximately” may be used. General terms, such as minutes, hours, or days, are acceptable, if necessary. DO NOT leave blank.
•The terminal event (for example, cardiac arrest or respiratory arrest) should not be used. If a mechanism of death seems most appropriate to
you for line (a), then you must always list its cause(s) on the line(s) below it (for example, cardiac arrest due to coronary artery atherosclerosis or
cardiac arrest due to blunt impact to chest).
• If an organ system failure such as congestive heart failure, hepatic failure, renal failure, or respiratory failure is listed as a cause of death,
always report its etiology on the line(s) beneath it (for example, renal failure due to Type I diabetes mellitus).
•When indicating neoplasms as a cause of death, include the following: 1) primary site or that the primary site is unknown, 2) benign or
malignant, 3) cell type or that the cell type is unknown, 4) grade of neoplasm, and 5) part or lobe of organ affected. (For example, a primary welldifferentiated squamous cell carcinoma, lung, left upper lobe.)
•Always report the fatal injury (for example, stab wound of chest), the trauma (for example, transection of subclavian vein), and impairment of
function (for example, air embolism).

PART II (Other significant conditions)
•Enter all diseases or conditions contributing to death that were not reported in the chain of events in Part I and that did not result in the
underlying cause of death. See attached examples.
•If two or more possible sequences resulted in death, or if two conditions seem to have added together, report in Part I the one that, in your
opinion, most directly caused death. Report in Part II the other conditions or diseases.

CHANGES TO CAUSE OF DEATH
Should additional medical information or autopsy findings become available that would change the cause of death originally reported, the original death
certificate should be amended by the certifying physician by immediately reporting the revised cause of death to the State Vital Records Office.

ITEMS 33-34 - AUTOPSY
•33 - Enter “Yes” if either a partial or full autopsy was performed. Otherwise enter “No.”
•34 - Enter “Yes” if autopsy findings were available to complete the cause of death; otherwise enter “No”. Leave item blank if no autopsy was
performed.

ITEM 35 - DID TOBACCO USE CONTRIBUTE TO DEATH?
Check “yes” if, in your opinion, the use of tobacco contributed to death. Tobacco use may contribute to deaths due to a wide variety of diseases;
for example, tobacco use contributes to many deaths due to emphysema or lung cancer and some heart disease and cancers of the head and
neck. Check “no” if, in your clinical judgment, tobacco use did not contribute to this particular death.

ITEM 36 - IF FEMALE, WAS DECEDENT PREGNANT AT TIME OF DEATH OR WITHIN PAST YEAR?
This information is important in determining pregnancy-related mortality.

ITEM 37 - MANNER OF DEATH
•Always check Manner of Death, which is important: 1) in determining accurate causes of death; 2) in processing insurance claims; and 3) in
statistical studies of injuries and death.
•Indicate “Pending investigation” if the manner of death cannot be determined whether due to an accident, suicide, or homicide within the
statutory time limit for filing the death certificate. This should be changed later to one of the other terms.
•Indicate “Could not be Determined” ONLY when it is impossible to determine the manner of death.

ITEMS 38-44 - ACCIDENT OR INJURY – to be filled out in all cases of deaths due to injury or poisoning.
•38 - Enter the exact month, day, and year of injury. Spell out the name of the month. DO NOT use a number for the month. (Remember, the
date of injury may differ from the date of death.) Estimates may be provided with “Approx.” placed before the date.
•39 - Enter the exact hour and minutes of injury or use your best estimate. Use a 24-hour clock.
•40 - Enter the general place (such as restaurant, vacant lot, or home) where the injury occurred. DO NOT enter firm or organization names.
(For example, enter “factory”, not “Standard Manufacturing, Inc.” )
•41 - Complete if anything other than natural disease is mentioned in Part I or Part II of the medical certification, including homicides, suicides,
and accidents. This includes all motor vehicle deaths. The item must be completed for decedents ages 14 years or over and may be completed
for those less than 14 years of age if warranted. Enter “Yes” if the injury occurred at work. Otherwise enter “No”. An injury may occur at work
regardless of whether the injury occurred in the course of the decedent’s “usual” occupation. Examples of injury at work and injury not at work
follow:
Injury at work
Injury not at work
Injury while engaged in personal recreational activity on job premises
Injury while working or in vocational training on job premises
Injury while a visitor (not on official work business) to job premises
Injury while on break or at lunch or in parking lot on job premises
Homemaker working at homemaking activities
Injury while working for pay or compensation, including at home
Student in school
Injury while working as a volunteer law enforcement official etc.
Injury while traveling on business, including to/from business contacts Working for self for no profit (mowing yard, repairing own roof, hobby)
Commuting to or from work
•42 - Enter the complete address where the injury occurred including zip code.
•43 - Enter a brief but specific and clear description of how the injury occurred. Explain the circumstances or cause of the injury. Specify
type of gun or type of vehicle (e.g., car, bulldozer, train, etc.) when relevant to circumstances. Indicate if more than one vehicle involved;
specify type of vehicle decedent was in.
•44 -Specify role of decedent (e.g. driver, passenger). Driver/operator and passenger should be designated for modes other than motor vehicles
such as bicycles. Other applies to watercraft, aircraft, animal, or people attached to outside of vehicles (e.g. surfers).
Rationale: Motor vehicle accidents are a major cause of unintentional deaths; details will help determine effectiveness of current safety features
and laws.
REFERENCES
For more information on how to complete the medical certification section of the death certificate, refer to tutorial at http://www.TheNAME.org and
resources including instructions and handbooks available by request from NCHS, Room 7318, 3311 Toledo Road, Hyattsville, Maryland 207822003 or at www.cdc.gov/nchs/about/major/dvs/handbk.htm

REV. 11/2003

Cause-of-death – Background, Examples, and Common Problems
Accurate cause of death information is important
•to the public health community in evaluating and improving the health of all citizens, and
•often to the family, now and in the future, and to the person settling the decedent’s estate.
The cause-of-death section consists of two parts. Part I is for reporting a chain of events leading directly to death, with the immediate cause of death (the final disease, injury, or complication directly causing death) on
line a and the underlying cause of death (the disease or injury that initiated the chain of events that led directly and inevitably to death) on the lowest used line. Part II is for reporting all other significant diseases,
conditions, or injuries that contributed to death but which did not result in the underlying cause of death given in Part I. The cause-of-death information should be YOUR best medical OPINION. A condition can be
listed as “probable” even if it has not been definitively diagnosed.

Examples of properly completed medical certifications
CAUSE OF DEATH (See instructions and examples)
32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition --------->
resulting in death)
Sequentially list conditions,
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

a.

Rupture of myocardium __________________________________________________________________________________

b.

Acute myocardial infarction_______________________________________________________________________________

c.

Coronary artery thrombosis_______________________________________________________________________________

Yes

Probably
Unknown

d.

Atherosclerotic coronary artery disease__________________________________________________________________

36. IF FEMALE:
■ Not pregnant within past year
Pregnant at time of death
Not pregnant, but pregnant within 42 days of death
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year

■ Natural
Accident
Suicide

Homicide
Pending Investigation
Could not be determined

CAUSE OF DEATH (See instructions and examples)

Sequentially list conditions,
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE
(disease or injury that
initiated the events resulting
in death) LAST

a.

Aspiration pneumonia_______________________________________________________________

b.

Complications of coma___________________________________________________________________________________

■ No

c.

Blunt force injuries________________________________________________________________________________________

d.

Motor vehicle accident____________________________________________________________________________________

Unknown

7 weeks

39. TIME OF INJURY

7 weeks

33. WAS AN AUTOPSY PERFORMED?
■ Yes
No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? ■ Yes No
37. MANNER OF DEATH

36. IF FEMALE:
Not pregnant within past year
Natural
Homicide
Pregnant at time of death
■ Accident
Pending Investigation
Not pregnant, but pregnant within 42 days of death
Suicide
Could not be determined
Not pregnant, but pregnant 43 days to 1 year before death
Unknown if pregnant within the past year
40. PLACE OF INJURY (e.g., Decedent’s home; construction site; restaurant; wooded area)
41. INJURY AT WORK?

Approx. 2320

road side near state highway

Yes ■ No

August 15, 2003
42. LOCATION OF INJURY:

7 weeks

Due to (or as a consequence of):

Probably

38. DATE OF INJURY
(Mo/Day/Yr) (Spell Month)

2 Days

Due to (or as a consequence of):

DID TOBACCO USE CONTRIBUTE TO DEATH?
Yes

Approximate interval:
Onset to death

Due to (or as a consequence of):

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

35.

7 years

33. WAS AN AUTOPSY PERFORMED?
■ Yes
No
34. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE THE CAUSE OF DEATH? ■ Yes No
37. MANNER OF DEATH

32. PART I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional
lines if necessary.
IMMEDIATE CAUSE (Final
disease or condition --------->
resulting in death)

5 years

Due to (or as a consequence of):

DID TOBACCO USE CONTRIBUTE TO DEATH?

No

6 days

Due to (or as a consequence of):

Diabetes, Chronic obstructive pulmonary disease, smoking

■

Minutes

Due to (or as a consequence of):

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I

35.

Approximate interval:
Onset to death

State: Missouri

Street & Number: mile marker 17 on state route 46a
43. DESCRIBE HOW INJURY OCCURRED:

City or Town: near Alexandria
Apartment No.:

Decedent driver of van, ran off road into tree

Zip Code:
44. IF TRANSPORTATION INJURY, SPECIFY:
■ Driver/Operator
Passenger
Pedestrian
Other (Specify)

Common problems in death certification
The elderly decedent should have a clear and distinct etiological sequence for cause of death, if possible. Terms such as senescence, infirmity, old age, and advanced age have little value for public health or medical
research. Age is recorded elsewhere on the certificate. When a number of conditions resulted in death, the physician should choose the single sequence that, in his or her opinion, best describes the process leading to
death, and place any other pertinent conditions in Part II. If after careful consideration the physician cannot determine a sequence that ends in death, then the medical examiner or coroner should be consulted about
conducting an investigation or providing assistance in completing the cause of death.
The infant decedent should have a clear and distinct etiological sequence for cause of death, if possible. “Prematurity” should not be entered without explaining the etiology of prematurity. Maternal conditions may have
initiated or affected the sequence that resulted in infant death, and such maternal causes should be reported in addition to the infant causes on the infant’s death certificate (e.g., Hyaline membrane disease due to
prematurity, 28 weeks due to placental abruption due to blunt trauma to mother’s abdomen).
When SIDS is suspected, a complete investigation should be conducted, typically by a medical examiner or coroner. If the infant is under 1 year of age, no cause of death is determined after scene investigation, clinical
history is reviewed, and a complete autopsy is performed, then the death can be reported as Sudden Infant Death Syndrome.
When processes such as the following are reported, additional information about the etiology should be reported:
Abscess
Carcinomatosis
Disseminated intra vascular
Abdominal hemorrhage
Cardiac arrest
coagulopathy
Adhesions
Cardiac dysrhythmia
Dysrhythmia
Adult respiratory distress syndrome
Cardiomyopathy
End-stage liver disease
Acute myocardial infarction
Cardiopulmonary arrest
End-stage renal disease
Altered mental status
Cellulitis
Epidural hematoma
Anemia
Cerebral edema
Exsanguination
Anoxia
Cerebrovascular accident
Failure to thrive
Anoxic encephalopathy
Cerebellar tonsillar herniation
Fracture
Arrhythmia
Chronic bedridden state
Gangrene
Ascites
Cirrhosis
Gastrointestinal hemorrhage
Aspiration
Coagulopathy
Heart failure
Atrial fibrillation
Compression fracture
Hemothorax
Bacteremia
Congestive heart failure
Hepatic failure
Bedridden
Convulsions
Hepatitis
Biliary obstruction
Decubiti
Hepatorenal syndrome
Bowel obstruction
Dehydration
Hyperglycemia
Brain injury
Dementia (when not
Hyperkalemia
Brain stem herniation
otherwise specified)
Hypovolemic shock
Carcinogenesis
Diarrhea

Hyponatremia
Hypotension
Immunosuppression
Increased intra cranial pressure
Intra cranial hemorrhage
Malnutrition
Metabolic encephalopathy
Multi-organ failure
Multi-system organ failure
Myocardial infarction
Necrotizing soft-tissue infection
Old age
Open (or closed) head injury
Paralysis
Pancytopenia
Perforated gallbladder
Peritonitis
Pleural effusions
Pneumonia

Pulmonary arrest
Pulmonary edema
Pulmonary embolism
Pulmonary insufficiency
Renal failure
Respiratory arrest
Seizures
Sepsis
Septic shock
Shock
Starvation
Subdural hematoma
Subarachnoid hemorrhage
Sudden death
Thrombocytopenia
Uncal herniation
Urinary tract infection
Ventricular fibrillation
Ventricular tachycardia
Volume depletion

If the certifier is unable to determine the etiology of a process such as those shown above, the process must be qualified as being of an unknown, undetermined, probable, presumed, or unspecified etiology so it is clear
that a distinct etiology was not inadvertently or carelessly omitted.
The following conditions and types of death might seem to be specific or natural but when the medical history is examined further may be found to be complications of an injury or poisoning (possibly occurring long ago).
Such cases should be reported to the medical examiner/coroner.
Asphyxia
Epidural hematoma
Hip fracture
Pulmonary emboli
Subdural hematoma
Bolus
Exsanguination
Hyperthermia
Seizure disorder
Surgery
Choking
Fall
Hypothermia
Sepsis
Thermal burns/chemical burns
Drug or alcohol overdose/drug or
Fracture
Open reduction of fracture
Subarachnoid hemorrhage
alcohol abuse

REV. 11/2003

FUNERAL DIRECTOR INSTRUCTIONS for selected items on U.S.
Standard Certificate of Death (For additional information concerning all items on certificate see Funeral
Directors’ Handbook on Death Registration)
ITEM 1. DECEDENT’S LEGAL NAME
Include any other names used by decedent, if substantially different from the legal name, after the abbreviation AKA (also known as) e.g. Samuel
Langhorne Clemens AKA Mark Twain, but not Jonathon Doe AKA John Doe

ITEM 5. DATE OF BIRTH
Enter the full name of the month (January, February, March etc.) Do not use a number or abbreviation to designate the month.

ITEM 7A-G. RESIDENCE OF DECEDENT (information divided into seven categories)
Residence of decedent is the place where the decedent actually resided. The place of residence is not necessarily the same as “home state” or
“legal residence”. Never enter a temporary residence such as one used during a visit, business trip, or vacation. Place of residence during a
tour of military duty or during attendance at college is considered permanent and should be entered as the place of residence. If the decedent
had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution, nursing home,
penitentiary, or hospital for the chronically ill, report the location of that facility in item 7. If the decedent was an infant who never resided at
home, the place of residence is that of the parent(s) or legal guardian. Never use an acute care hospital’s location as the place of residence for
any infant. If Canadian residence, please specify Province instead of State.

ITEM 10. SURVIVING SPOUSE’S NAME
If the decedent was married at the time of death, enter the full name of the surviving spouse. If the surviving spouse is the wife, enter her name
prior to first marriage. This item is used in establishing proper insurance settlements and other survivor benefits.

ITEM 12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE
Enter the name used prior to first marriage, commonly known as the maiden name. This name is useful because it remains constant throughout
life.

ITEM 14. PLACE OF DEATH
The place where death is pronounced should be considered the place where death occurred. If the place of death is unknown but the body is
found in your State, the certificate of death should be completed and filed in accordance with the laws of your State. Enter the place where the
body is found as the place of death.

ITEM 51. DECEDENT’S EDUCATION (Check appropriate box on death certificate)
Check the box that corresponds to the highest level of education that the decedent completed. Information in this section will not appear on
the certified copy of the death certificate. This information is used to study the relationship between mortality and education (which
roughly corresponds with socioeconomic status). This information is valuable in medical studies of causes of death and in programs
to prevent illness and death.

ITEM 52. WAS DECEDENT OF HISPANIC ORIGIN? (Check “No” or appropriate “Yes” box)
Check “No” or check the “Yes” box that best corresponds with the decedent’s ethnic Spanish identity as given by the informant. Note that
“Hispanic” is not a race and item 53 must also be completed. Do not leave this item blank. With respect to this item, “Hispanic” refers to people
whose origins are from Spain, Mexico, or the Spanish-speaking Caribbean Islands or countries of Central or South America. Origin includes
ancestry, nationality, and lineage. There is no set rule about how many generations are to be taken into account in determining Hispanic origin; it
may be based on the country of origin of a parent, grandparent, or some far-removed ancestor. Although the prompts include the major Hispanic
groups, other groups may be specified under “other”. “Other” may also be used for decedents of multiple Hispanic origin (e.g. Mexican-Puerto
Rican). Information in this section will not appear on the certified copy of the death certificate. This information is needed to identify
health problems in a large minority population in the United States. Identifying health problems will make it possible to target public
health resources to this important segment of our population.

ITEM 53. RACE (Check appropriate box or boxes on death certificate)
Enter the race of the decedent as stated by the informant. Hispanic is not a race; information on Hispanic ethnicity is collected separately in item
52. American Indian and Alaska Native refer only to those native to North and South America (including Central America) and does not include
Asian Indian. Please specify the name of enrolled or principal tribe (e.g., Navajo, Cheyenne, etc.) for the American Indian or Alaska Native. For
Asians check Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or specify other Asian group; for Pacific Islanders check
Guamanian or Chamorro, Samoan, or specify other Pacific Island group. If the decedent was of mixed race, enter each race (e.g., SamoanChinese-Filipino or White, American Indian). Information in this section will not appear on the certified copy of the death certificate.
Race is essential for identifying specific mortality patterns and leading causes of death among different racial groups. It is also used
to determine if specific health programs are needed in particular areas and to make population estimates.

ITEMS 54 AND 55. OCCUPATION AND INDUSTRY
Questions concerning occupation and industry must be completed for all decedents 14 years of age or older. This information is useful in
studying deaths related to jobs and in identifying any new risks. For example, the link between lung disease and lung cancer and asbestos
exposure in jobs such as shipbuilding or construction was made possible by this sort of information on death certificates. Information in this
section will not appear on the certified copy of the death certificate.

ITEM 54. DECEDENT’S USUAL OCCUPATION
Enter the usual occupation of the decedent. This is not necessarily the last occupation of the decedent. Never enter “retired”. Give kind of work
decedent did during most of his or her working life, such as claim adjuster, farmhand, coal miner, janitor, store manager, college professor, or
civil engineer. If the decedent was a homemaker at the time of death but had worked outside the household during his or her working life, enter
that occupation. If the decedent was a homemaker during most of his or her working life, and never worked outside the household, enter
“homemaker”. Enter “student” if the decedent was a student at the time of death and was never regularly employed or employed full time during
his or her working life. Information in this section will not appear on the certified copy of the death certificate.

ITEM 55. KIND OF BUSINESS/INDUSTRY
Kind of business to which occupation in item 54 is related, such as insurance, farming, coal mining, hardware store, retail clothing, university, or
government. DO NOT enter firm or organization names. If decedent was a homemaker as indicated in item 54, then enter either “own home” or
“someone else’s home” as appropriate. If decedent was a student as indicated in item 54, then enter type of school, such as high school or
college, in item 55. Information in this section will not appear on the certified copy of the death certificate.
NOTE: This recommended standard death certificate is the result of an extensive evaluation process. Information on the process and resulting
recommendations as well as plans for future activities is available on the Internet at: http://www.cdc.gov/nchs/vital_certs_rev.htm.
REV. 11/2003

Attachment G. 42 USC § 3735

Attachment H. Mailing Packet

3040 Cornwallis Road  PO Box 12194
Research Triangle Park, NC 27709-2194
ATTN: Matt Bensen 0213149.001.400.402.100

Bureau of Justice Statistics (Bureau) – Confidentiality Assurances 
42 USC § 3735 ‐ Use of Data 
Data collected by the Bureau shall be used only for statistical or research purposes, and shall be gathered in a manner 
that precludes their use for law enforcement or any purpose relating to a private person or public agency other than 
statistical or research purposes. 

42 USC § 3789g ‐ Confidentiality of information  
(a) Research or statistical information; immunity from process; prohibition against admission as evidence or use in 
any proceedings  
No officer or employee of the Federal Government, and no recipient of assistance under the provisions of this chapter 
shall use or reveal any research or statistical information furnished under this chapter by any person and identifiable to 
any specific private person for any purpose other than the purpose for which it was obtained in accordance with this 
chapter. Such information and copies thereof shall be immune from legal process, and shall not, without the consent of 
the person furnishing such information, be admitted as evidence or used for any purpose in any action, suit, or other 
judicial, legislative, or administrative proceedings.  
(b) Criminal history information; disposition and arrest data; procedures for collection, storage, dissemination, and 
current status; security and privacy; availability for law enforcement, criminal justice, and other lawful purposes; 
automated systems: review, challenge, and correction of information  
All criminal history information collected, stored, or disseminated through support under this chapter shall contain, to 
the maximum extent feasible, disposition as well as arrest data where arrest data is included therein. 
The collection, storage, and dissemination of such information shall take place under procedures reasonably designed to 
insure that all such information is kept current therein; the Office of Justice Programs shall assure that the security and 
privacy of all information is adequately provided for and that information shall only be used for law enforcement and 
criminal justice and other lawful purposes. In addition, an individual who believes that criminal history information 
concerning him contained in an automated system is inaccurate, incomplete, or maintained in violation of this chapter, 
shall, upon satisfactory verification of his identity, be entitled to review such information and to obtain a copy of it for 
the purpose of challenge or correction. 
(c) Criminal intelligence systems and information; prohibition against violation of privacy and constitutional rights of 
individuals  
All criminal intelligence systems operating through support under this chapter shall collect, maintain, and disseminate 
criminal intelligence information in conformance with policy standards which are prescribed by the Office of Justice 
Programs and which are written to assure that the funding and operation of these systems furthers the purpose of this 
chapter and to assure that such systems are not utilized in violation of the privacy and constitutional rights of 
individuals.  
(d) Violations; fine as additional penalty 
 Any person violating the provisions of this section, or of any rule, regulation, or order issued there under, shall be fined 
not to exceed $10,000, in addition to any other penalty imposed by law.  

January 11, 2016
«Salutation» «ContactFirstName» «ContactLastName»
«Agency Name»
«ContactAddress1»
«ContactAddress2»
«ContactCity», «ContactState» «ContactZip»
Dear «Salutation» «ContactLastName»:
Thanks to the efforts of state prison officials nationwide, the Bureau of Justice Statistics’ (BJS) Deaths in Custody
Reporting Program (DCRP) continues to be a great success. Started in 2000 with the passage of the Death in
Custody Reporting Act, which was reauthorized in December of 2014, the DCRP is the only source of data on
prisoner deaths.
This letter marks the beginning of the 2016 DCRP data collection cycle, and we hope you will participate in this
important data collection.
Please use the following credentials to log onto the DCRP Web site (https://bjsdcrp.rti.org) to access the
2015 and 2016 forms:
USERNAME: «username»
PASSWORD: «password»
Please submit all 2015 data, including the Annual Summary of Inmate Deaths in State Prisons form (NPS-4) and
the corresponding State Prison Inmate Death Report forms (NPS-4A), by February 29, 2016.
BJS will use the data collected under the DCRP for research and statistical purposes only, as described in Title 42,
USC §3735 and 3789g (enclosed). As with all BJS data collections, the data will be stored securely at all times.
If you have questions about the DCRP, please contact Matt Bensen, the RTI data collection task leader, at (800)
344-1387 or bjsdcrp@rti.org.
We thank you in advance for your participation and look forward to our continued work together.
Sincerely,

Margaret E. Noonan, Program Manager
Deaths in Custody Reporting Program
(202) 353-2060
margaret.noonan@usdoj.gov

Anastasios Tsoutis, Chief
Corrections Unit
(202) 305-9079

anastasios.tsoutis@usdoj.gov

Enclosures: DCRP Update, 2015 Reporting Instructions, 2016 Reporting Instructions, Confidentiality Assurances

ACTION REQUESTED
2015 Reporting Instructions
All agencies should submit a 2015 NPS-4 Annual Summary form,
even if no deaths occurred in your agency’s custody during 2015.
 To submit data, please log onto the Deaths in Custody Reporting
Program (DCRP) Web site (https://bjsdcrp.rti.org) with your
username and password below:
Username:
Password:


To submit via paper, access the 2015 NPS-4 and the 2015 NPS4A forms on the DCRP Web site (https://bjsdcrp.rti.org) and print
them. Please mail or fax these according to the form instructions.

ACTION REQUESTED
2016 Reporting Instructions
 If no deaths have occurred in your agency’s custody to date in
2016, do not report anything at this time.
 Please submit a 2016 NPS-4A Death Report form for each death
that occurs in your agency’s custody in 2016.
 Please provide an answer for ALL questions on the form,
including “Specify” fields, if applicable.
 To submit data, please log onto the Deaths in Custody Reporting
Program (DCRP) Web site (https://bjsdcrp.rti.org) with your
username and password below:
Username:
Password:
 Please refer to the Frequently Asked Questions section of the
DCRP Web site (https://bjsdcrp.rti.org) for additional information.

RY2015 Verification Call Script 
Introduction 
Hello. My name is [FILL]. I am calling on behalf of the U.S. Department of Justice.  
I am trying to reach [FILL] about the Deaths in Custody Reporting Program. 

[OR] 
I am trying to reach the person who is responsible for reporting your agency’s data to the 
Deaths in Custody Reporting Program. (Last year, our primary contact was [FILL]). 

IF NAMED POC 
‐‐NO LONGER WORKDS THERE: 
‐‐IS UNKNOWN TO THE PERSON: 
‐‐IS UNAVAILABLE: 
ASK WHO MIGHT BE THE APPROPRIATE PERSON TO CONTACT ABOUT THE DEATHS IN CUSTODY 
REPORTING PROGRAM 
IF NAMED POC IS AVAILABLE OR ANOTHER PERSON INDICATES WILLINGNESS TO HELP, EXPLAIN 
REASON FOR CALL 
We appreciate your participation in the Deaths in Custody Reporting Program. 
In preparation for sending the annual DCRP package to you in January, we would like to make sure that 
the information we have on file for your agency is still correct. We also have a population‐based 
question. This should only take a few minutes. 
IF “NO,” FIND A GOOD TIME TO CALL BACK AND PRESS END CALL 
IF “YES,” PRESS CONTINUE 

1 

Agency Information  
First, I’d like to confirm that we have the correct name for your agency… [FILL] Is your agency name 
accurate? 
[IF “NO”] What is the correct name of your agency? 
We have the following as the physical address for your agency… [FILL] 

[IF ~”NOT RIGHT”] What is the correct physical address for your agency? 

Point of Contact Information 
Our files indicate that ([FILL] / YOU) should be the primary contact for providing us with death reports 
and agency‐level summary data for the Deaths in Custody Reporting Program. Is this correct? 
[If “NO,” GATHER INFORMATION FOR NEW POINT OF CONTACT, INCLUDING: Salutation/Title, 
First Name, Last Name, Mailing Address (Street, City, State, and Zip Code), Phone Number, E‐
mail Address] 
[IF “YES”] I would like to review the contact information we have on file for [FILL] / YOU.  
[REVIEW THE FOLLOWING: Salutation/Title, First Name, Last Name, Mailing Address 
(Street, City, State, and Zip Code), Phone Number, E‐mail Address] 

Agency Head Information 
We would like to collect some information about the head of your agency. Our files indicate that [FILL] is 
the head of your agency. Is this correct? 
[If “NO,” GATHER INFORMATION FOR NEW AGENCY HEAD, INCLUDING: Salutation/Title, First 
Name, Last Name, Mailing Address (Street, City, State, and Zip Code), Phone Number, E‐mail 
Address] 
[IF “YES”] I would like to review the contact information we have on file for [FILL] / YOU.  
[REVIEW THE FOLLOWING: Salutation/Title, First Name, Last Name, Mailing Address 
(Street, City, State, and Zip Code), Phone Number, E‐mail Address] 
Given that we may need to use the agency head contact information throughout the upcoming year, we 
would like to ask you a couple of questions to verify that [FILL]/YOU will remain the agency head for the 
foreseeable future.  
[IF PRIOR TO NOVEMBER ELECTION DAY] Is the agency head position up for re‐election in November 
2015? 
[IF AFTER NOVEMBER ELECTION DAY] Was the agency head position up for re‐election in November 
2015? 

[IF “YES”] Was/Were [FILL] / YOU re‐elected? 

[IF “NO”]  
2 

1) Who is the newly elected agency head? 
2) When will the newly elected agency head take office? 
3) Do you have a telephone number and/or e‐mail address for the newly elected 
agency head? 

Facility Information 
I now want to verify the facilities that are operating within your jurisdiction. First, BJS considers a facility 
to be separate if it has its own administrator, its own staff, and its own budget. Second, when it comes 
to the Deaths in Custody Reporting Program, an eligible facility meets the following criteria:  



It is not a temporary holding or lockup facility from which inmates are transferred within 72 
hours and not held beyond arraignment 
It does not exclusively hold inmates aged 17 or younger.  

We have [FILL] facility/facilities listed under your jurisdiction. 
[READ FACILITY NAME, ADDRESS, CITY, AND ZIP] Is this information correct? 
[CYCLE THROUGH THE QUESTIONS ON THIS PAGE FOR EACH EXISTING FACILITY FOR WHICH THE POC 
WISHES TO AMEND INFORMATION. IF THE POC IS ADDING A NEW FACILITY, MOVE TO THE NEW 
FACILITIES TO OUR DATABASE SECTION ON THE FOLLOWING PAGE.] 

[IF “NO”] What kinds of changes do we need to make to our records for [FILL]? 

[IF FACILITY CLOSED PART OR ALL OF THE YEAR] When did this facility close? 

Do you expect this facility to re‐open? 

Where are inmates from this facility being sent? 

[IF “YES”] When do you expect this facility to re‐open? 

[IF FACILTY NOW IN A DIFFERENT JURISDICTION] What is the name of the agency that 
supervises [FILL] now? 
Do you happen to know the name and telephone number of the person we 
should contact about the facility now? 
[IF CONSOLIDATED WITH ANOTHER FACILITY] Please tell me the names of the facilities 
that have consolidated. Just so you know, we may follow up with you at a later date if 
we have any further questions about this consolidation. 
[IF NAME OR ADDRESS CHANGE NEEDED, COLLECT UPDATED INFORMATION] 

[IF MISCELLANEOUS INFORMATION] Please tell us about the other changes that we 
should make to ensure that the information that we have for [FILL] is complete and 
accurate. Just so you know, we may follow up with you at a later date if we have any 
further questions about this facility change. 

3 

Do you include data for this facility when you report to DCRP? 
[IF “NO”] Would you please provide a name and telephone number for the person who could 
provide us with information on [FILL]? 
Before moving forward, I would like to verify that all of these facilities are currently open and operating. 
Is this a complete list of all the facilities in your jurisdiction? 
New Facilities to Our Database 
[IF “NO”] We would like to ask you a few questions to ensure that this facility is eligible for the 
DCRP data collection. Is this facility exclusively used as a temporary holding or a lockup facility 
from which inmates are usually transferred within 72 hours and not held beyond arraignment? 
[IF “NO”] Does this facility exclusively hold inmates 17 or younger? 
[IF “YES” TO ONE OF THE ABOVE TWO QUESTIONS, THE FACILITY IS INELIGIBLE. OUR AGENCY 
LIASION WOULD SAY “Thank you for this information. This particular facility is not eligible for 
DCRP because [FILL REASON].” 
[IF “NO”] Thank you for this helpful information. I would like to collect the name and 
address for this facility. 
What date did this facility open? 
Does this facility exclusively hold inmates for the state Department of Corrections? 
Does this complete the list of facilities in your jurisdiction? 
[IF “NO,” CYCLE BACK THROUGH THE QUESTIONS IN THE NEW FACILITIES TO OUR 
DATABASE SECTION.] 
[End of Questions for New Facilities] 
We want to know a little bit about the populations that are held with your facility/facilities. 
Do you hold juveniles at any of your facilities? 
[IF YES AND MORE THAN ONE FACILITY] Which facilities?  
Other than courtesy holds, does your agency hold any inmates for Immigration and Customs 
Enforcement (ICE)?  

[IF YES AND MORE THAN ONE FACILITY] Which facilities? 

Other than courtesy holds, does your agency hold any U.S. Marshal inmates? 

[IF YES AND MORE THAN ONE FACILITY] Which facilities? 

Other than courtesy holds, does your agency hold inmates for state or federal prisons, Bureau of Indian 
Affairs, or any other counties or jurisdictions? 

[IF YES AND MORE THAN ONE FACILITY] Which facilities? 
4 

Data Submission Status 
Thank you. Regarding 2014: 
[IF ALL PRIOR YEAR REPORTS WERE SUBMITTED] Thank you for submitting all of your reports for 
2014.  
[IF NO PRIOR YEAR REPORTS WERE SUBMITTED] Our records show that we have not received 
your agency’s 2014 Annual Summary form. All agencies should complete the Annual Summary 
form each year, even those that did not experience a death in custody.  
[IF MISSING PRIOR YEAR DEATH REPORTS, BUT ASF WAS SUBMITTED] Our records show that we 
have received your agency’s 2014 Annual Summary form. However, we are still expecting [FILL] 
death report(s). ). A death report is expected for each death reported on the Annual Summary 
Form.  
[IF MISSING PRIOR YEAR ASF, BUT DEATH REPORTS WERE SUBMITTED] Our records show that 
we have received [FILL] death report(s). However, we have not received your agency’s 2014 
Annual Summary form. All agencies should complete an Annual Summary form each year.  
Also, please know that you can now submit 2015 death reports online, via mail, email or fax. Would you 
like me to provide you with your username and password so you can log in and submit your reports 
online? 
Thank you for your help today. Do you have any questions for me? 

5