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pdfDEATH IN CUSTODY REPORTING ACT
Fiscal Year 20XX
U.S. DEPARTMENT OF JUSTICE
BUREAU OF JUSTICE ASSISTANCE
ACTING AS COLLECTION AGENT:
***
FORM DCR-1A
For each reportable death identified in your Quarterly Summary, please respond to all of the following questions regarding
the decedent’s characteristics and the circumstances surrounding the death. Information provided on this form must have
originated from official government records, documents, or personnel. You will not be able to SAVE the information
unless all fields are completed.
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:
Decedent Name (Last, First, Middle Initial)
Date of Death
Time of Death
Location of Event Causing the Death (Street Address, City, State, Zip)
1.
2.
3.
4.
What was the decedent’s sex?
Male
Female
5.
What location category best describes where the
event causing the death occurred? (Mark only one)
Residence/home
Law enforcement facility
What was the decedent’s date of birth (or approximate
age at death if DOB is unknown)?
Business – please specify type: _______________
____________________________________________
Other – please specify: _____________________
Unknown
Unknown
What was the decedent’s ethnic origin? (Mark only
one)
Hispanic or Latino
Not Hispanic or Latino
Unknown
6.
Law enforcement agency that detained, arrested, or
was in the process of arresting the deceased:
______________________________________________
7.
What was the decedent’s race? (Mark all that apply)
Facility Type (if applicable):
Municipal or County Jail
State Prison
American Indian or Alaska Native
State-Run Boot Camp Prison
Asian
Contracted Boot Camp Prison
Black or African American
Any State or Local Contract Facility
Native Hawaiian or Other Pacific Islander
Other Local or State Correctional Facility (to include
any juvenile facilities)
White
Other
Unknown
OMB number XXX-XXXX, expires on XX/XX/20XX
8.
Brief description of the circumstances surrounding
the death:
Natural causes
Other – please specify: _______________________
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File Type | application/pdf |
File Modified | 2018-07-16 |
File Created | 2018-07-16 |