Quarterly Summary LEA Input

DEATH IN CUSTODY REPORTING ACT
Fiscal Year 20XX

U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE ASSISTANCE
ACTING AS COLLECTION AGENT:
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FORM DCR-1: QUARTERLY SUMMARY
The Quarterly Summary is a list of reportable deaths that occurred in your State during the current reporting period.
Please complete this form and include all requested information. For each death identified in the Quarterly Summary,
you must complete a corresponding Incident Report (Form DCR-1A) which collects additional required information on the
decedent’s characteristics and circumstances surrounding the death. The information included on this form will
automatically populate the same fields in the corresponding Incident Report form.
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:

SECTION A
Was there at least one (1) reportable death in your jurisdiction during this quarter?




Yes [Proceed to Section B below]
No [STOP. No other information is required]

SECTION B
Decedent name (Last, First, Middle Initial)

Date of Death

1

Time of Death

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

Responsible State or Local Agency

2

Type of Agency:  Law Enforcement Agency
Decedent name (Last, First, Middle Initial)

Agency ORI

 Correctional Agency
Date of Death

Time of Death

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

Responsible State or Local Agency

3

Type of Agency:  Law Enforcement Agency
Decedent name (Last, First, Middle Initial)

Agency ORI

 Correctional Agency
Date of Death

Time of Death

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

Responsible State or Local Agency

Type of Agency:

 Law Enforcement Agency

Agency ORI

 Correctional Agency

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