CJ-5B Survey of Jails in Indian Country with COVID-19 addendum

Attachment A. Forms CJ-5B for 2019, 2020, and 2021 SJIC
CJ-5B
RETURN
TO

Ben Korelitz
Survey of Jails in Indian Country
Westat
1600 Research Boulevard
Rockville, MD 20850
RW 2632

FORM

CJ-5B
(07-01-19)

OMB No.1121-0364: Approval Expires 5/31/2022

U.S. DEPARTMENT OF JUSTICE

2019 ANNUAL
SURVEY OF JAILS
IN INDIAN COUNTRY

BUREAU OF JUSTICE STATISTICS
AND ACTING AS COLLECTION AGENT

WESTAT

Data Supplied by
Name

Title

Address

Number and street or P.O. box/Route

Telephone

Area Code

State
Fax Number

Number

Area Code

Zip Code

Number

E-Mail
Address

GENERAL INFORMATION


If you have any questions about completing this form, please contact Karla Eisen of Westat at 1-888-675-7330 or
BJS Statistician, Jennifer Bronson at 202-616-8937, jennifer.bronson@usdoj.gov.



Please mail your completed questionnaire to Westat before August 16, 2019 or FAX (all) pages to 301-315-5934.
Please retain a copy of the completed form for your records.

Who does this survey cover?
All confinement facilities, including detention centers, jails, and other correctional facilities operated by tribal authorities or
the Bureau of Indian Affairs.
 INCLUDE special jail facilities (e.g., medical/treatment/release centers, halfway houses, and work farms).
All persons under your jail supervision.
 INCLUDE all confined adults and juveniles (i.e., persons under age 18).
 INCLUDE persons on transfer to treatment facilities but who remain under your legal jurisdiction.
 INCLUDE persons held for other jurisdictions.
What data are to be excluded from this survey?
 EXCLUDE inmates on AWOL, escape, or long-term transfer to other jurisdictions.
 EXCLUDE any persons housed in a correctional facility not operated by your jurisdiction.

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 1 1/4 hours 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.

Page 2

Page 3

FORM CJ-5B (07-01-19)

11. Of the total number of JAIL OPERATION EMPLOYEES
reported in item 10b, how many had received —
a. The basic detention officer
certification? ...................


INCLUDE BIA or State certification.

b.40 hours of in-service training? ...
12. On June 28, 2019 what was the total rated capacity
of this facility?


EXCLUDE temporary spaces such as tents, trailers, and
other temporary space.



Rated capacity is the maximum number of beds or inmates
assigned by a rating official to this facility.



If rated capacity is not available, estimate by using the
design capacity and mark the box.

Page 4

INSTRUCTIONS
• If the answer to a question is “not available” or “unknown,” write “DK” in the space
provided.
• If the answer to a question is “not applicable,” write “NA” in the space provided.
• If the answer to a question is “none” or “zero,” write “0” in the space provided.
• When exact numeric answers are not available, provide estimates and mark in the box
beside each figure that is estimated. For example, 1,234

SECTION 1—INMATE COUNTS AND MOVEMENT
1. On June 30, 2020, how many persons were CONFINED in this facility?
INCLUDE—
 Persons on transfer to treatment facilities but who remain under your jurisdiction.
 Persons held for other jurisdictions.
EXCLUDE—
 Inmates on AWOL escape, or long-term transfer to other jurisdictions.
___________□

Number confined
2. On June 30, 2020, how many persons CONFINED in this facility were—
a. Males age 18 or older

___________□

b. Females age 18 or older

___________□

c. Males under age 18

___________□

d. Females under age 18

___________□

e. TOTAL (Sum of items 2a to 2d should equal item 1)

___________□

3. Of all male and female juveniles CONFINED in this facility on June 30, 2020, how
many were tried or awaiting trial in ADULT court?
Number of juveniles
(under age 18) held as adults

___________□

4. Of all male and female adults CONFINED in this facility on June 30, 2020, how many
were ages—
a. 18-24

___________□

b. 25-34

___________□

c. 35-44

___________□

d. 45-54

___________□

e. 55-64

___________□

f.

___________□

65 or older

g. TOTAL (Sum of items 4a to 4f should equal the sum of items
___________□

2a and 2b)

5. Of persons CONFINED in this facility on June 30, 2020, how many were—
•

For persons with more than one charge/offense, report the status
associated with the most serious charge/offense.

•

For convicted inmates, include probation and parole violators with no
new sentence.

a. Convicted

___________□

b. Unconvicted

___________□

c. TOTAL (Sum of items 5a and 5b should equal the sum of item 1)

___________□

6. On June 30, 2020 how many persons CONFINED in this facility, regardless of
conviction status, had as their most serious offense—
a. Domestic violence offense

___________□

 INCLUDE assault, abuse, cruelty, or threat to a spouse, intimate, or a
dependent child.
b. Assault

___________□

 INCLUDE aggravated and simple assault.
 EXCLUDE domestic violence offenses and rape/sexual assault.
c. Rape/sexual assault
 EXCLUDE domestic violence offenses and assaults reported in
item 6b.
d. Other violent offenses
 EXCLUDE domestic violence offenses, assaults, and rape/sexual
assault.
e. Burglary
• Also known as breaking and entering.

___________□

___________□
___________□

___________□

f. Larceny-theft
 EXCLUDE motor-vehicle theft.

___________□

g. A drug law violation
 INCLUDE offenses relating to the unlawful possession,
distribution, sale, use, growing, or manufacturing of
narcotic drugs.
h. Driving while intoxicated or driving under the influence
of alcohol or drugs

___________□

i. Public intoxication

___________□

• Also known as “drunk and disorderly.”
j. Other offenses

___________□

k. TOTAL (Sum of items 6a to 6j should equal the sum of item 1)

___________□

7. On June 30, 2020 how many persons CONFINED in this facility, regardless of
conviction status, had an offense type of—
• For persons with more than one charge/offense, report the most serious
type of charge/offense.
a. Felony

___________□

b. Misdemeanor

___________□

c. Other—Specify
______________________

___________□

d. TOTAL (Sum of items 7a to 7c should equal the sum of item 1)

___________□

8. During the 30 day period from June 1, 2020 to June 30, 2020—
a. What was the average daily population of this jail facility?
• To calculate the average daily population, add the number of
persons confined in this facility for each day during the period
June 1-30, 2020, and divide the results by 30.
Average daily population

___________□

b. On what day did this facility hold the greatest number of
persons?
June ___________, 2020

c. How many persons were CONFINED on that day?
Number confined

___________□

9. During the 30 day period from June 1, 2020 to June 30, 2020, how many persons
were—
a. New admissions to this jail facility
 INCLUDE persons officially booked into and housed in this jail facility by formal legal
document or by the authority of the courts or some other official agency.
 EXCLUDE returns from escape, work release, medical appointments/treatment
facilities, and bail and court appearances.
New admissions

___________□

b. Final discharges from this jail facility
 INCLUDE all persons released after a period of confinement (e.g., sentence
completion, bail/bond, other pretrial release, transfers to other jurisdictions, and death).
 EXCLUDE temporary discharges (e.g., work releases, medical appointments/treatment
facilities, to courts, furloughs, day reporters, and transfers to other facilities within your
jurisdiction).
Final discharges

___________□

10. Between July 1, 2019 and June 30, 2020—
a. How many inmates died while under the supervision of this jail facility?
INCLUDE all deaths of persons— 
CONFINED in this jail facility.
 UNDER YOUR JAIL JURISDICTION but out to court or in special facilities (e.g., at
hospitals, halfway houses, work farms, and medical/treatment/release centers).
 WHILE IN-TRANSIT to or from this jail facility while under your supervision.
EXCLUDE—
 Persons who were NOT admitted into this jail facility, and died during the INTAKE
process.
•

Enter 0 if no deaths.
Number of deaths

b. Of those who died, how many committed suicide?

__________□

Number of completed suicides

___________□

c. How many persons ATTEMPTED suicide while CONFINED in
this jail facility?
Number of attempted suicides

___________□

SECTION II—FACILTY OPERATIONS AND STAFF
For items 11 and 12, please respond based on the inclusionary and exclusionary
instructions below.
INCLUDE—
 Full-time and part-time staff, payroll staff that are tribal or BIA direct-funded staff (e.g., 638
contract and self-governance).
 Nonpayroll staff employed by other tribal/governmental agencies (staff provided by IHS,
education, or other human service departments or courts).
 Contract nonpayroll staff paid through private service contracts (e.g., food service,
healthcare, maintenance, transportation).
EXCLUDE—
 Community volunteers and unpaid interns.
11. Of the total number of CORRECTIONAL employees on June 30, 2020, how many were
in—
• Count each employee only once. Classify employees with multiple functions by the function
performed most frequently.
a. Administration
___________□
 INCLUDE the jail administrators, assistants and other
personnel who work in an administrative capacity more than
50% of the time.
b. Jail operations

___________□

 INCLUDE correctional officers, guards, and other staff who
spend more than 50% of their time supervising inmates.
c. Educational

___________□

 INCLUDE academic and vocational staff.
d. Technical/professional staff
INCLUDE—
 Counselors, psychiatrists, psychologists, social workers,
dentists, medical staff, and other professional staff.
 Dispatchers with no inmate supervision duties.

___________□

___________□

e. Clerical, maintenance, and food service
f.

Other—Specify
______________________

___________□
___________□

g. TOTAL (Sum of items 11a to 11f)

12. Of the total number of JAIL OPERATION employees (item 11b), how many had
received—
a. The basic detention officer certification?
___________□
 INCLUDE BIA or State certification.

___________□

b. 40 hours of in-service training?

13. On June 30, 2020, what was the total rated capacity of this facility?


EXCLUDE temporary spaces such as tents, trailers, and other
temporary space.

• Rated capacity is the maximum number of beds or inmates assigned by a
rating official to this facility.
• If rated capacity is not available, estimate by using the design capacity
and mark the box.
Rated capacity

___________□

SECTION III—SPECIAL ADDENDUM ON CORONAVIRUS (COVID-19)
14. Between January 2020 and May 2020, how many persons were CONFINED in this jail
facility on the last weekday of each month—
Number of inmates—
a. January 31, 2020

___________□

b. February 28, 2020

___________□

c. March 31, 2020

___________□

d. April 30, 2020

___________□

e. May 29, 2020

___________□

15. Between March 1, 2020, and June 30, 2020, how many persons CONFINED in this
jail facility received expedited release in response to the coronavirus?
 INCLUDE releases in order to limit inmate risk and exposure, or due to coronavirusrelated understaffing, court orders, legislative mandates, etc.
___________□
16a. Between March 1, 2020, and June 30, 2020, how many coronavirus TESTS were
conducted on persons CONFINED in this jail facility?
• Coronavirus test refers to the viral tests for COVID-19. Do not count serology tests (also
known as antibody tests).
INCLUDE—
 Tests conducted either on or off facility grounds (e.g., at hospitals, medical centers,
private labs, patient service centers, and other health vendors).
 Tests conducted on persons on transfer to treatment facilities, but who remained
under the jurisdiction of this jail facility.
EXCLUDE—
 Antibody tests that are used to detect antibodies produced in response to
coronavirus, but do not confirm current infection.
 Suspected cases that were showing symptoms of coronavirus, but were not tested.
 Persons who tested positive for the coronavirus during the INTAKE process, and
therefore were NOT admitted into this jail facility.



___________□

b. Of those tested (item 16a), how many TESTS were positive? • ___________□

17. Individual may test positive for the coronavirus multiple times. Between March 1,
2020, and June 30, 2020, how many PERSONS confined in this jail facility tested
POSITIVE?
• Multiple positive results for the same individual should be counted only once.
___________□
18. Between March 1, 2020, and June 30, 2020, how many CORRECTIONAL employees in
this jail facility tested POSITIVE for the coronavirus?

• Refer to item 11 for correctional staff definitions.
• Multiple positive results for the same individual should be counted only once.
INCLUDE—
Correctional employees tested either on or off facility grounds (e.g., at hospitals, medical
centers, private labs, patient service centers, and other health vendors).
EXCLUDE—
 Antibody tests that are used to detect antibodies produced in response to coronavirus, but
do not confirm current infection.
 Suspected cases that were showing symptoms of coronavirus, but were not tested.
___________□
19a. Between March 1, 2020, and June 30, 2020, how many INMATES DIED from the
coronavirus while under the supervision of this jail facility?
INCLUDE all deaths from coronavirus of persons—
 CONFINED in this jail facility.
 UNDER YOUR JAIL JURISDICTION but out to court or in special facilities (e.g., at
hospitals, halfway houses, work farms, and medical/treatment/release centers).
 WHILE IN-TRANSIT to or from this jail facility while under your supervision.
 Regardless of when and where the inmate contracted coronavirus.
EXCLUDE—
 Persons who were NOT admitted into this jail facility and died during the INTAKE
process.
(1) Confirmed deaths from coronavirus

___________□

• Deaths where coronavirus was the cause of death OR a significant contributor to the
death as determined by a positive test for coronavirus before or after death.
(2) Suspected deaths from coronavirus

___________□

• Deaths where coronavirus was the suspected cause of death OR a significant
contributor to the death based on the person having symptoms of coronavirus, but no
positive test for coronavirus.
(3) Total number of INMATE deaths (sum of items 19a1 and 19a2)

___________□

How many deaths were based on a medical examiner’s or coroner’s
evaluation (such as an autopsy, postmortem exam, or review of medical
records)?
___________□

b. Between March 1, 2020, and June 30, 2020, how many CORRECTIONAL

employees in this jail facility DIED from the coronavirus?
INCLUDE—
 Correctional employee deaths that occurred either on or off facility grounds (e.g., while
on duty, in the hospital, at home, etc.).
 Correctional employee deaths regardless of when and where staff contracted
coronavirus.
(1) Confirmed deaths from coronavirus

___________□

• Deaths where coronavirus was the cause of death OR a significant contributor to the
death as determined by a positive test for coronavirus before or after death.
(2) Suspected deaths from coronavirus

___________□

• Deaths where coronavirus was the suspected cause of death OR a significant
contributor to the death based on the person having symptoms of coronavirus, but no
positive test for coronavirus.
(3) Total number of CORRECTIONAL employee deaths (sum of items
19b1 and 19b2)
___________□
How many deaths were based on a medical examiner’s or coroner’s
evaluation (such as an autopsy, postmortem exam, or review of medical
records)?
___________□

END OF SURVEY
NOTES

INSTRUCTIONS
• If the answer to a question is “not available” or “unknown,” write “DK” in the space
provided.
• If the answer to a question is “not applicable,” write “NA” in the space provided.
• If the answer to a question is “none” or “zero,” write “0” in the space provided.
• When exact numeric answers are not available, provide estimates and mark in the box
beside each figure that is estimated. For example, 1,234

SECTION 1—INMATE COUNTS AND MOVEMENT
1. On June 30, 2021, how many persons were CONFINED in this facility?
INCLUDE—
 Persons on transfer to treatment facilities but who remain under your jurisdiction. 
Persons held for other jurisdictions.
EXCLUDE—
 Inmates on AWOL escape, or long-term transfer to other jurisdictions.
Number confined ___________□
2. On June 30, 2021, how many persons CONFINED in this facility were—
a. Males age 18 or older

___________□

b. Females age 18 or older

___________□

c. Males under age 18

___________□

d. Females under age 18

___________□

e. TOTAL (Sum of items 2a to 2d should equal item 1)

___________□

3. Of all male and female juveniles CONFINED in this facility on June 30, 2021, how
many were tried or awaiting trial in ADULT court?
Number of juveniles
(under age 18) held as adults ___________□
4. Of all male and female adults CONFINED in this facility on June 30, 2021, how many
were ages—
a. 18-24

___________□

b. 25-34

___________□

c. 35-44

___________□

d. 45-54

___________□

e. 55-64

___________□

f.

___________□

65 or older

g. TOTAL (Sum of items 4a to 4f should equal the sum of items
___________□

2a and 2b)

5. Of persons CONFINED in this facility on June 30, 2021, how many were—
•

For persons with more than one charge/offense, report the status
associated with the most serious charge/offense.

•

For convicted inmates, include probation and parole violators with no
new sentence.

a. Convicted

___________□

b. Unconvicted

___________□

c. TOTAL (Sum of items 5a and 5b should equal the sum of item 1) ___________□
6. On June 30, 2021 how many persons CONFINED in this facility, regardless of
conviction status, had as their most serious offense—
___________□

a. Domestic violence offense

 INCLUDE assault, abuse, cruelty, or threat to a spouse, intimate, or a
dependent child.
___________□

b. Assault

 INCLUDE aggravated and simple assault.
 EXCLUDE domestic violence offenses and rape/sexual assault.
___________□

c. Rape/sexual assault

 EXCLUDE domestic violence offenses and assaults reported in
item 6b.
d. Other violent offenses
___________□
 EXCLUDE domestic
rape/sexual assault.

violence

offenses,

assaults,

and

e. Burglary

___________□

• Also known as breaking and entering.
f. Larceny-theft

___________□

 EXCLUDE motor-vehicle theft.
g. A drug law violation

___________□

 INCLUDE offenses relating to the unlawful possession,
distribution, sale, use, growing, or manufacturing of
narcotic drugs.
h. Driving while intoxicated or driving under the influence
of alcohol or drugs

___________□

i. Public intoxication

___________□

• Also known as “drunk and disorderly.”
j. Other offenses

___________□

k. TOTAL (Sum of items 6a to 6j should equal the sum of item 1)

___________□

7. On June 30, 2021 how many persons CONFINED in this facility, regardless of
conviction status, had an offense type of—
• For persons with more than one charge/offense, report the most serious
type of charge/offense.
a. Felony
___________□
b. Misdemeanor

___________□

c. Other—Specify
______________________

___________□

d. TOTAL (Sum of items 7a to 7c should equal the sum of item 1)

___________□

8. During the 30 day period from June 1, 2021 to June 30, 2021—
a. What was the average daily population of this jail facility?
• To calculate the average daily population, add the number
of persons confined in this facility for each day during the
period June 1-30, 2021, and divide the results by 30.

Average daily population

___________□

b. On what day did this facility hold the greatest number of
persons?
June ___________, 2021
c. How many persons were CONFINED on that day?
Number confined ___________□
9. During the 30 day period from June 1, 2021 to June 30, 2021, how many persons
were—
a. New admissions to this jail facility
 INCLUDE persons officially booked into and housed in this jail facility by formal legal
document or by the authority of the courts or some other official agency.
 EXCLUDE returns from escape, work release, medical appointments/treatment
facilities, and bail and court appearances.
New admissions

___________□

b. Final discharges from this jail facility
 INCLUDE all persons released after a period of confinement (e.g., sentence
completion, bail/bond, other pretrial release, transfers to other jurisdictions, and death).
 EXCLUDE temporary discharges (e.g., work releases, medical appointments/treatment
facilities, to courts, furloughs, day reporters, and transfers to other facilities within within
your jurisdiction).
Final discharges

___________□

10. Between July 1, 2020 and June 30, 2021—
a. How many inmates died while under the supervision of this jail facility?
INCLUDE all deaths of persons— 
CONFINED in this jail facility.
 UNDER YOUR JAIL JURISDICTION but out to court or in special facilities (e.g., at
hospitals, halfway houses, work farms, and medical/treatment/release centers).
 WHILE IN-TRANSIT to or from this jail facility while under your supervision.
EXCLUDE—
 Persons who were NOT admitted into this jail facility, and died during the INTAKE
process.
•

Enter 0 if no deaths.

Number of deaths

___________□

b. Of those who died, how many committed suicide?
Number of completed suicides

___________□

c. How many persons ATTEMPTED suicide while CONFINED in
this jail facility?
Number of attempted suicides

___________□

SECTION II—FACILTY OPERATIONS AND STAFF
For items 11 and 12, please respond based on the inclusionary and exclusionary
instructions below.
INCLUDE—
 Full-time and part-time staff, payroll staff that are tribal or BIA direct-funded staff (e.g., 638
contract and self-governance).
 Nonpayroll staff employed by other tribal/governmental agencies (staff provided by IHS,
education, or other human service departments or courts).
 Contract nonpayroll staff paid through private service contracts (e.g., food service,
healthcare, maintenance, transportation).
EXCLUDE—
 Community volunteers and unpaid interns.
11. Of the total number of CORRECTIONAL employees on June 30, 2021, how many were
in—
• Count each employee only once. Classify employees with multiple functions
by the function performed most frequently.
a. Administration
___________□
 INCLUDE the jail administrators, assistants and other
personnel who work in an administrative capacity more than
50% of the time.
b. Jail operations

___________□

 INCLUDE correctional officers, guards, and other staff who
spend more than 50% of their time supervising inmates.
c. Educational
 INCLUDE academic and vocational staff.

___________□

___________□

d. Technical/professional staff
INCLUDE—
 Counselors, psychiatrists, psychologists, social workers,
dentists, medical staff, and other professional staff.
 Dispatchers with no inmate supervision duties.

___________□

e. Clerical, maintenance, and food service
f.

Other—Specify
______________________

___________□

g.TOTAL (Sum of items 11a to 11f)

___________□

12. Of the total number of JAIL OPERATION employees (item 11b), how many had
received—
___________□

a. The basic detention officer certification?
 INCLUDE BIA or State certification.

___________□

b. 40 hours of in-service training?

13. On June 30, 2021, what was the total rated capacity of this facility?
 EXCLUDE temporary spaces such as tents, trailers, and other temporary
space.
• Rated capacity is the maximum number of beds or inmates assigned by a
rating official to this facility.
• If rated capacity is not available, estimate by using the design capacity and
mark the box.
Rated capacity

___________□

SECTION III—SPECIAL ADDENDUM ON CORONAVIRUS (COVID-19)
14. Between July 2020 and December 2020, how many persons were CONFINED in this jail
facility on the last weekday of each month—
Number of inmates—
a. July 31, 2020

___________□

b. August 31, 2020

___________□

c. September 30, 2020

___________□

d. October 30, 2020

___________□

e. November 30, 2020

___________□

f.

___________□

December 31, 2020

15. Between July 1, 2020, and December 31, 2020, how many persons CONFINED in
this jail facility received expedited release in response to the coronavirus?
 INCLUDE releases in order to limit inmate risk and exposure, or due to coronavirusrelated understaffing, court orders, legislative mandates, etc.
___________□
16a. Between July 1, 2020, and December 31, 2020, how many coronavirus TESTS were
conducted on persons CONFINED in this jail facility?
• Coronavirus test refers to the viral tests for COVID-19. Do not count serology tests (also
known as antibody tests).
INCLUDE—
 Tests conducted either on or off facility grounds (e.g., at hospitals, medical centers,
private labs, patient service centers, and other health vendors).
 Tests conducted on persons on transfer to treatment facilities, but who remained
under the jurisdiction of this jail facility.
EXCLUDE—
 Antibody tests that are used to detect antibodies produced in response to
coronavirus, but do not confirm current infection.
 Suspected cases that were showing symptoms of coronavirus, but were not tested.
 Persons who tested positive for the coronavirus during the INTAKE process, and
therefore were NOT admitted into this jail facility.



___________□

b. Of those tested (item 16a), how many TESTS were positive? • ___________□

17. Individual may test positive for the coronavirus multiple times. Between July 1, 2020,
and December 31, 2020, how many PERSONS confined in this jail facility tested POSITIVE?
• Multiple positive results for the same individual should be counted only once.
___________□

18. Between July 1, 2020, and December 31, 2020, how many CORRECTIONAL
employees in this jail facility tested POSITIVE for the coronavirus?
• Refer to item 11 for correctional staff definitions.
• Multiple positive results for the same individual should be counted only once.
INCLUDE—
Correctional employees tested either on or off facility grounds (e.g., at hospitals, medical
centers, private labs, patient service centers, and other health vendors).
EXCLUDE—
 Antibody tests that are used to detect antibodies produced in response to coronavirus, but
do not confirm current infection.
 Suspected cases that were showing symptoms of coronavirus, but were not tested.
___________□
19a. Between July 1, 2020, and December 31, 2020, how many INMATES DIED from the
coronavirus while under the supervision of this jail facility?
INCLUDE all deaths from coronavirus of persons—
 CONFINED in this jail facility.
 UNDER YOUR JAIL JURISDICTION but out to court or in special facilities (e.g., at
hospitals, halfway houses, work farms, and medical/treatment/release centers).
 WHILE IN-TRANSIT to or from this jail facility while under your supervision.
 Regardless of when and where the inmate contracted coronavirus.
EXCLUDE—
 Persons who were NOT admitted into this jail facility and died during the INTAKE
process.
(1) Confirmed deaths from coronavirus

___________□

• Deaths where coronavirus was the cause of death OR a significant contributor to the
death as determined by a positive test for coronavirus before or after death.
(2) Suspected deaths from coronavirus

___________□

• Deaths where coronavirus was the suspected cause of death OR a significant
contributor to the death based on the person having symptoms of coronavirus, but no
positive test for coronavirus.
(3) Total number of INMATE deaths (sum of items 19a1 and 19a2)

___________□

How many deaths were based on a medical examiner’s or coroner’s
evaluation (such as an autopsy, postmortem exam, or review of medical
records)?
___________□
b. Between July 1, 2020, and December 31, 2020, how many CORRECTIONAL

employees in this jail facility DIED from the coronavirus?
INCLUDE—
 Correctional employee deaths that occurred either on or off facility grounds (e.g., while
on duty, in the hospital, at home, etc.).
 Correctional employee deaths regardless of when and where staff contracted
coronavirus.
(1) Confirmed deaths from coronavirus

___________□

• Deaths where coronavirus was the cause of death OR a significant contributor to the
death as determined by a positive test for coronavirus before or after death.
(2) Suspected deaths from coronavirus

___________□

• Deaths where coronavirus was the suspected cause of death OR a significant
contributor to the death based on the person having symptoms of coronavirus, but no
positive test for coronavirus.
(3) Total number of CORRECTIONAL employee deaths (sum of items
19b1 and 19b2)
___________□
How many deaths were based on a medical examiner’s or coroner’s
evaluation (such as an autopsy, postmortem exam, or review of medical
records)?
___________□

END OF SURVEY
NOTES