Juvenile Residential Facility Census

Juvenile Residential Facilty Census (JRFC)

Non-Substantive Change OMB No. 1121-0219

Juvenile Residential Facilty Census

OMB: 1121-0219

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Draft #3 (4/15/2022)

Conducted by
U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU
FOR
OFFICE OF JUVENILE JUSTICE AND
DELINQUENCY PREVENTION

U.S. DEPARTMENT OF JUSTICE

Juvenile Residential Facility Census
QUESTIONNAIRE FOR

This questionnaire asks about services, staff, and persons
assigned beds in this facility on Wednesday, OCTOBER 26, 2022.

PLEASE COMPLETE AND MAIL THIS FORM IN THE ENCLOSED
ENVELOPE BY NOVEMBER 30, 2022
Return the completed form to:

U.S. CENSUS BUREAU
P.O. BOX 5000
JEFFERSONVILLE, IN 47199-5000
ERD/JRFC
WEBSITE: https://respond.census.gov/jrfc
Fax: 1–888–262–3974

If you have any questions, call Jonathan Albers at 1–800–352–7229
or email govs.JRFC@census.gov

PERSON COMPLETING THIS QUESTIONNAIRE
Name

E-mail address

Title
Telephone

Business address – Number and street/or P.O. Box/Route number
Area code

Number

Area code

Number

Extension

Fax Number
City
FORM

CJ-15 (10-23-2022)

State

ZIP Code

OMB No. 1121-0219: Approval Expires 11/30/2023

Section 1 – GENERAL FACILITY INFORMATION

IMPORTANT INSTRUCTIONS
IMPORTANT INSTRUCTIONS

Please call 1–800–352–7229 to request an
additional questionnaire for each building with
living/sleeping units associated with this facility
that is not at the site of this facility building or
campus.

Complete this questionnaire for the facility listed
on the cover. If additional questionnaires are
needed for other facilities for which you report,
call 1–800–352–7229 to request more forms.
A juvenile residential facility is a place where
young persons who have committed offenses
may be housed overnight. A facility has
living/sleeping units, such as wings, floors,
dorms, barracks, or cottages on one campus or
in one building.
Any buildings with living/sleeping units that are
not on the same campus should be considered
separate facilities and should be recorded on
separate questionnaires in this census.

Is the PREPRINTED facility name and mailing
address on the BACK cover page of this form
correct, or do they need to be corrected?
01

Preprinted facility name and mailing address on the
BACK cover page of this form are correct

Preprinted facility name or mailing address need
to be corrected – Please make necessary
corrections on the BACK cover page of this form.

On Wednesday, October 26, 2022, did this
facility house any overﬁow detention
population? "Overflow detention population" refers to
those young persons who, because of the unavailability
of beds in a detention center, are placed temporarily in
a non-detention facility.
If this is a detention center, mark (X) "No".
01

Yes

IMPORTANT INSTRUCTIONS
The following items ask you to use your records to
provide counts of persons who had assigned beds
in this facility at the end of the day on Wednesday,
October 26, 2022. This date has been chosen
carefully to give a standardized count of persons in
facilities like yours across the country. You will be
asked to classify your facility population into two
age groups:
1. those persons under age 21; and

Which of the following best describes the
physical layout of this facility?
Mark (X) ONLY ONE response.
This facility is –
01

a part of one building

all of one building

more than one building at a single site or on
one campus
Other – Specify

2. those persons age 21 and older.
You will then be asked to classify each person
UNDER THE AGE OF 21 into just one of the two
following categories:
1. those here because they have been charged
with or court-adjudicated for an offense. An
offense is any behavior that is illegal in your
state for underage persons alone or for both
underage persons and adults.
2. those here for reasons other than offenses
Detailed descriptions of the above categories are
provided in the questions themselves.
Please use your records for October 25, 2000, to
answer the following questions.

Page 2

Are there any other buildings with
living/sleeping units that are associated with
this facility that are not next to this facility
building or on the same campus?
01

Yes

FORM CJ-15 (10-23-2022)

Section 1 – GENERAL FACILITY INFORMATION – Continued
5a. According to your records, at the end of the

day on Wednesday, October 26, 2022, did ANY
persons have assigned beds in this facility?
Include persons who were temporarily away, but had
assigned beds on October 26. Do NOT include staff
01

Yes ➔

Go to Question 5d

7a. At the end of the day on Wednesday,

October 26, 2022, did ANY persons UNDER
AGE 21 have assigned beds in this facility?
INCLUDE juveniles being tried as adults in criminal court.
Do NOT include staff.
01

Yes ➔

Go to Question 7b

b. On Wednesday, October 26, 2022, no persons

had assigned beds in this facility because this
facility was:
01

Permanently closed

Temporarily closed

Open, but did not have any persons assigned beds
on Wednesday, October 26, 2022 for a different
reason.

c. Specify why there were not ANY persons

assigned beds in your facility on Wednesday,
October 26, 2022: Mark (X) all that apply.
01

02
03
04

This facility is no longer under contract to hold
youth charged with or adjudicated for delinquency
or status offenses.
This facility is (or was) under renovation.
No juveniles in facility on Wednesday, October 26,
2022
Other – please specify

INSTRUCTIONS:
1. If you DID NOT have ANY persons
UNDER AGE 21 assigned beds in this
facility on Wednesday, October 26, 2022,
STOP HERE and mail this form ONLY.
2. If you DID HAVE persons UNDER AGE
21 assigned beds in this facility on
Wednesday, October 26, 2022,
CONTINUE BELOW.

b. According to your records, at the end of the

day on Wednesday, October 26, 2022, how
many young persons under age 21 had
assigned beds in this facility? Include young
persons who were temporarily away but had assigned
beds on October 26. Do NOT include staff.

Young persons under the age of 21
INSTRUCTIONS: If you did NOT have
ANY persons assigned beds in this facility
on Wednesday, October 26, 2022, STOP
HERE and mail this form.

d. According to your records, at the end of the
day on Wednesday, October 26, 2022, how
many persons had assigned beds in this
facility?

Persons
6. How many of the persons who had assigned
beds at the end of the day on Wednesday,
October 26, 2022 were AGE 21 or older?

Include persons who were temporarily away, but had
assigned beds on Wednesday, October 26, 2022.
Do NOT include staff. Please write "0" if there are
NO persons age 21 or older.
Persons 21 or older

FORM CJ-15 (10-23-2022)

Page 3

Section 1 – GENERAL FACILITY INFORMATION – Continued
8a. At the end of the day on Wednesday,
October 26, 2022, did ANY of the young
persons UNDER AGE 21 have assigned
beds in this facility SPECIFICALLY BECAUSE
they were CHARGED WITH OR COURTADJUDICATED FOR AN OFFENSE?
An offense is any behavior that is illegal in your state
for underage persons alone or for both underage
persons and adults.
INCLUDE in your count persons UNDER AGE 21 here
BECAUSE THEY WERE CHARGED WITH OR
ADJUDICATED FOR:

● ANY offense that is illegal for both adults and

8b. According to your records for the end of the

day on Wednesday, October 26, 2022, HOW
MANY YOUNG PERSONS UNDER AGE 21 had
assigned beds in the facility SPECIFICALLY
BECAUSE they were CHARGED WITH OR
COURT-ADJUDICATED FOR AN OFFENSE, as
deﬁned in question 8a?
Include young persons who were temporarily away
but had assigned beds on October 26. Do NOT
include staff.
Young persons under age 21 here
because they were charged with or
court-adjudicated for an offense.

underage persons.
● AN offense that is ILLEGAL IN YOUR STATE for
underage persons but not for adults. Examples are
running away, truancy, incorrigibility, curfew violation,
and underage liquor violations. Count persons with
these behaviors here ONLY IF THE BEHAVIORS
ARE ILLEGAL IN YOUR STATE. This includes those
CHINS (Children in Need of Services) and PINS
(Persons in Need of Services) who are here
BECAUSE of an offense.
● ANY offense being adjudicated in juvenile or criminal
court, including a probation or parole violation.
DO NOT INCLUDE here:
● Young persons under age 21 who have committed
one or more offenses in the past, BUT HAVE
ASSIGNED BEDS ON OCTOBER 26 FOR
REASONS OTHER THAN OFFENSES.
● Young persons under 21 assigned beds here
BECAUSE OF REASONS OTHER THAN
OFFENSES, such as neglect, abuse, dependency,
abandonment, mental health problems, substance
abuse problems. These persons will be counted in
questions 9a and 9b.
● Young persons under 21 who have run away, been
truant or incorrigible, or violated curfew, IF THESE
BEHAVIORS ARE NOT CONSIDERED ILLEGAL IN
YOUR STATE. These young persons will be counted
in questions 9a and 9b.
● Those persons who are PINS (Persons in Need of
Services) or CHINS (Children in Need of Services)
who have assigned beds because of REASONS
OTHER THAN OFFENSES. These young persons
will be counted in questions 9a and 9b.

Page 4

Yes

No ➔

Go to Question 9a on page 5

FORM CJ-15 (10-23-2022)

Section 1 – GENERAL FACILITY INFORMATION – Continued

9a. At the end of the day on Wednesday,

10a.

October 26, 2022, did ANY of the young
persons UNDER AGE 21 have assigned beds
in this facility FOR REASONS OTHER THAN
OFFENSES? DO NOT include staff.
INCLUDE here:
● Young persons under age 21 assigned beds here for
NON-OFFENSE REASONS, such as neglect, abuse,
dependency, abandonment, mental health problems,
substance abuse problems, or another non-offense
reason

Does this facility provide ON-SITE
RESIDENTIAL TREATMENT?
01

Yes

➔

Go to Question 11

b. (if yes) What kind of treatment is provided
INSIDE this facility? Mark (X) all that apply.

● Young persons under age 21 who have committed
one or more offenses in the past, BUT ARE
ASSIGNED BEDS HERE ON OCTOBER 26 FOR
REASONS OTHER THAN THESE OFFENSES
● Young persons under age 21 who have run away,
been truant or incorrigible, or violated curfew, IF
THESE BEHAVIORS ARE NOT CONSIDERED
ILLEGAL IN YOUR STATE.

Mental health treatment

Substance abuse treatment

03
04

Sex offender treatment
Treatment for arsonists

Treatment specifically for violent offenders

Behavioral modification or therapy

Trauma treatment

Anger management

Other – Specify

● Young persons assigned beds here due to voluntary
or non-offense related admissions.

Do NOT INCLUDE:

11.

● Young persons assigned beds here BECAUSE THEY
WERE CHARGED WITH OR COURT-ADJUDICATED
FOR AN OFFENSE. These persons are counted in
questions 8a and 8b.
01

Yes

No ➔

12.
Go to NOTE below

b. According to your records for the end of the

Does this facility provide foster care?
01

Yes, for all young persons

Yes, for some but not all young persons

Does this facility provide independent living
arrangements for any young persons?
01

Yes

day on Wednesday, October 26, 2022, HOW
MANY YOUNG PERSONS UNDER AGE 21 had
assigned beds in this facility FOR REASONS
OTHER THAN OFFENSES, AS DEFINED IN 9a?
Include young persons who were temporarily away but
had assigned beds on October 26. Do NOT include
staff.
Young persons under age 21 here
because of non-offense reasons.
NOTE
As a check, the sum of question 8b
(young persons under 21 with offense)
and 9b (young persons under 21 with
non-offense) should equal 7b (total
young persons under age 21).

FORM CJ-15 (10-23-2022)

Page 5

Section 1 – GENERAL FACILITY INFORMATION – Continued
13.

What type of residential facility is the one listed
on the front cover? Mark (X) all that apply.
01

Long-term secure facility: A specialized type
of facility that provides strict confinement and
long-term treatment generally for post-adjudication
committed youth charged with or adjudicated for
delinquency or status offenses. Includes training
schools, juvenile correctional facilities, youth
development centers.
Reception or diagnostic center: A short-term
facility that screens youth charged with or
adjudicated for delinquency or status offenses,
committed by the courts and assigns them to
appropriate correctional facilities.
Group home/Halfway house: These facilities
are generally non-secure and typically intended for
post adjudication commitments in which young
persons are allowed extensive contact with the
community, such as attending school or holding a
job.

Residential treatment center: A facility that
focuses on providing some type of individually
planned treatment program for youth (substance
abuse, sex offender, mental health, etc.) in
conjunction with residential care. Such facilities
generally require specific licensing by the state
that may require that treatment provided is
Medicaid-reimbursable.

Page 6

Detention center: A short-term facility that
provides temporary care in a physically restricting
environment for juveniles in custody pending court
disposition and, often, for juveniles who are
adjudicated delinquent and awaiting disposition or
placement elsewhere, or are awaiting transfer to
another jurisdiction. In some jurisdictions, detention
centers may also hold juveniles committed for short
periods of time as part of their disposition (e.g.,
weekend detention).

14a.

Boot camp: A secure facility that operates like
military basic training. It is designed to combine
elements of basic military training programs,
correctional components and treatment programs.
The emphasis is on strict discipline, drills, and
work.
Ranch, forestry camp, wilderness or marine
program or farm: These are long-term generally
non-secure residential facilities often located in a
relatively remote area. The juveniles participate in a
structured program that emphasizes outdoor work,
including conservation and related activities.
Runaway and homeless shelter: A short-term
facility that provides temporary care in a physically
unrestricted environment. It can also provide
longer-term care under a juvenile court disposition order.
Other type of shelter: This includes emergency
non-secure shelters where juveniles are housed
short-term until another placement can be found.
Other: This includes independent living programs
and anything that cannot be classified above.
Specify

Does this facility have one or more
living/sleeping units, such as wings, ﬁoors,
dorms, barracks, or cottages, for the purpose
of keeping any young persons separate in
housing and activities from other residents
for specialized care or security? Do NOT
include time-out rooms, isolation rooms or infirmaries.
IF THE ONLY REASON for separate housing and
activities ARE SEX OR AGE, ANSWER NO.

Yes

➔

Go to NOTE A on page 7

(If yes) Do any of these separate
living/sleeping units differ in terms of –
Mark (X) all that apply.
01

average length of stay of young persons

physical security and/or monitoring of young
persons

number of staff per young person

type of treatment program

characteristics of young persons

specialized criteria for staff selection

other? – Specify

c. What is the purpose for having separate

living/sleeping units? Mark (X) all that apply.

To provide two or more types of specialized
care in separate living/sleeping units

To provide a series of separate living/sleeping
units with different specialized care that all
young persons move through from the time
they enter until the time they leave

To provide two or more levels of security

Some other reason – Specify

d. Do the separate living/sleeping units within
this facility share any of the following –

Mark (X) all that apply.
01

The same agency affiliation

The same mailing address

The same on-site administrators

One or more staff directly caring for the
young persons

One or more security staff

The same school rooms

The same dining room at the same time

The same recreational areas at the same time

The same laundry services

None of the above services are shared
FORM CJ-15 (10-23-2022)

Section 1 – GENERAL FACILITY INFORMATION – Continued
NOTE
A

15a.

Is this facility OWNED by one or more of
the following –
Mark (X) all that apply.
01
a private non-profit agency
02

a for profit agency

a government agency

➔

Go to
NOTE B

What is the level of the government agency
that OWNS this facility?
Mark (X) all that apply.

Yes

➔

Go to Question 20

When are young persons in this facility
locked into their sleeping rooms by staff?
01

When they are out of control

When they are suicidal

Rarely, no set schedule

During shift changes

Whenever they are in their sleeping rooms

At night

Part of each day

Most of each day

A Native American Tribal Government

All of each day

Federal

Other – Specify

State

County

Municipal (includes Washington, DC)

Other – Specify

20.

Questions 17 and 18 ask who
OPERATES this facility.

Is this facility OPERATED by one or more
of the following –
Mark (X) all that apply.
01

a private non-profit agency

a for profit agency

a government agency

➔

Go to Question 18

What is the name of the private non-profit or
for-proﬁt agency that OPERATES this facility?
Go to
Question
19a

What is the level of the government agency
that OPERATES this facility (either directly or
under a contract with)?
Mark (X) all that apply.
01

A Native American Tribal Government

Federal

State

County

Municipal (includes Washington, DC)

Other – Specify

FORM CJ-15 (10-23-2022)

Does this facility have any of the following
features intended to secure or conﬁne
young persons within speciﬁc areas?
Mark (X) all that apply.
01

Doors for secure day rooms that are locked by
staff to confine young persons within specific
areas or rooms

Wing, floor, corridor, or other internal security
doors that are locked by staff to confine young
persons within specific areas
Outside doors that are locked by staff to
confine young persons within specific buildings

➔
18.

Are ANY young persons in this facility
locked into their sleeping rooms by staff at
ANY time to conﬁne them?

Mark (X) all that apply.

What is the name of the private non-profit or
for-proﬁt agency that OWNS this facility?

NOTE
B

17a.

Go to Question 16

➔
16.

19a.

Questions 15 and 16 ask who OWNS
this facility. Later you will be asked who
OPERATES this facility.

21a.

External gates in fences or walls WITHOUT
razor wire that are locked by staff to confine
young persons

External gates in fences or walls WITH razor
wire that are locked to confine young persons

Other – Specify

The facility has none of the above features.

Are outside doors to any buildings with
living/sleeping units in this facility ever
locked?
01

Yes

➔

Go to Question 22 on page 8

Page 7

Section 1 – GENERAL FACILITY INFORMATION – Continued
21b.

WHEN are outside doors to buildings with
living/sleeping units in this facility locked?
Mark (X) all that apply.

Mark (X) all that apply.

24.

On the night of Wednesday, October 26, 2022,
what were the sleeping room arrangements
for young persons assigned beds in this
facility in terms of the number of ACTUAL
OCCUPANTS per sleeping room? Answer in terms
of the actual occupancy status on October 26, 2022,
regardless of whether it reflects the occupancy for which
the sleeping room(s) was/were originally designed, and
whether or not young persons slept on makeshift beds
within these sleeping rooms.

Why are outside doors to buildings with
living/sleeping units in this facility locked?
01

To keep intruders out

To keep young persons inside this facility

Rarely, no set schedule

At night

Part of each day

Most of each day

All of each day

When the facility is unoccupied

4 young persons per sleeping room

Other – Specify

Between 5 and 10 young persons per sleeping
room

Between 11 and 25 young persons per sleeping
room
More than 25 young persons per sleeping room

1 young person per sleeping room (single
occupancy)

2 young persons per sleeping room (double
occupancy)
3 young persons per sleeping room (triple
occupancy)

22.

What was the TOTAL NUMBER OF STANDARD
BEDS for young persons in this facility on the
night of Wednesday, October 28, 2020?
Do NOT include staff beds.
● A single bed is one standard bed
● A double bunked bed is two standard beds

Total number of standard beds

23a.

On the night of Wednesday, October 26,
2022, were there ANY OCCUPIED
MAKESHIFT BEDS in this facility?
Makeshift beds are:
● Roll-out mats
● Fold-out cots
● Roll-away beds
● Pull-out mattresses
● Sofas
● Any other beds that are put away or
moved during non-sleeping hours

Yes

➔

Go to Question 24

How many makeshift beds were occupied
that night?

Occupied makeshift beds

Page 8

FORM CJ-15 (10-23-2022)

Section 2 – MENTAL HEALTH SERVICES
1a.

After arrival in this facility, are ANY young
persons asked questions or administered a
form which asks questions to determine risk
for suicide?
01

Yes

➔

When are young persons FIRST asked
questions or administered a form which asks
questions to determine risk of suicide?
Mark (X) all that apply.
01

Go to Question 6 on page 10

What best describes the process through
which young persons are asked questions or
administered a form which asks questions
to determine risk of suicide?

03
04

Within less than 24 hours after arrival
Between 24 hours and less than 7 days after
arrival
Seven or more days after arrival
Other – Specify

Mark (X) all that apply.
01

02
03

04
05
06
07

One or more questions about suicide
incorporated into the medical history or
intake process
A form or questions designed by this facility to
assess suicide risk
A form or questions designed by a county or
state juvenile justice system to assess suicide
risk
MAYSI- Full Form
MAYSI- Suicide/depression module
V-DISC
Other – Specify

Which young persons are asked questions
or administered a form which asks questions
to determine risk of suicide?
Mark (X) all that apply.
01

ALL young persons are asked questions or
administered a form which asks questions to
determine suicide risk ➔ Go to Question 5a

Young persons who come directly from home,
rather than from another facility
Young persons who display or communicate
suicide risk
Young persons known to have prior suicide
attempts
Young persons for whom no mental health
care record is available
Other young persons not listed above – Specify

03
04
05

IMPORTANT NOTE
"Mental health professionals" are limited in this
census to – psychiatrists, psychologists with at least
a Master’s degree in PSYCHOLOGY, and social
workers with at least a Master’s in SOCIAL WORK
(MSW, LCSW).
"Counselors" in this census are persons with a
Master’s degree in a field other than psychology or
social work, or persons whose highest degree is a
Bachelor’s in any field.

5a.

Are ANY young persons re-asked questions
or re-administered a form which asks
questions to determine risk for suicide?
01
02

Who asks questions or administers a form
which asks questions to determine risk of
suicide?
Mark (X) all that apply.
01

Counselors/intake workers who have NOT been
trained by mental health professionals

Counselors/intake workers who have been
trained by mental health professionals
A mental health professional, as defined in the
box above

03
04

Go to Question 6 on page 10

Which best describes the conditions under
which young persons are re-asked questions
or re-administered a form that asks
questions to determine suicide risk?
Mark (X) all that apply.
01

02
03

Some other person – Specify
04

FORM CJ-15 (10-23-2022)

Yes
No ➔

No young persons are re-asked questions or
re-administered a form which asks questions
to determine suicide risk
As necessary on a case-by-case basis
Systematically, based on length of stay, facility
events, or negative life events (for example, after
each court appearance, every time the young person
re-enters the facility, after a death in the family)
Other – Specify

Page 9

Section 2 – MENTAL HEALTH SERVICES – Continued
6.

Does this facility assign different levels of
risk to young persons based on their
perceived risk of suicide?
01

Yes

NOTE
D

7a.

Yes
No ➔

Do young persons assigned beds receive
mental health services other than a suicide
evaluation either INSIDE or OUTSIDE this
facility?
Mental health services include:
● evaluations and appraisals conducted by
mental health professionals to diagnose or to
identify mental health needs
● ongoing mental health therapy
● ongoing counseling

Are young persons who are determined to
be at risk for suicide ever placed in a
sleeping room or observation room that is
locked or under staff security?
01

The following questions ask about preventative
measures taken once a young person is
identified to be at risk for suicide. Please
include all levels of suicide risk used by this
facility, if any, when answering these
questions.

NOTE
E

Go to Question 8

Which of the following best describes what
happens in the sleeping room or observation
room that is locked or under staff security?

03
04

Mark (X) all that apply.

Camera observation

15 minute staff checks

5 minute staff checks

Line of site supervision (direct or through glass)

Staff assigned to doorway or in sleeping
room/One-on-one supervision/Arms length
supervision

Other – Specify

10a.

No preventative measures are taken when a young
person is determined to be at risk for suicide

One-on-one supervision/Arms length supervision

Yes, provided both INSIDE and OUTSIDE
this facility
Yes, provided INSIDE this facility
Yes, provided OUTSIDE this facility
No, this facility does not provide mental
health services ➔ Go to Question 16a on page 12

Is ongoing COUNSELING provided for these
mental health problems provided INSIDE or
OUTSIDE this facility by a COUNSELOR?
Counselors are limited to:
● persons with a Master’s degree in a field other
than psychology or social work
● persons whose highest degree is a Bachelor’s
in any field.

Are any of the following preventative
measures taken when a young person is
determined to be at risk for suicide?
Mark (X) all that apply.

Questions 9 through 18 ask about mental
health services provided at a location either
INSIDE or OUTSIDE this facility. INSIDE
refers to any location on the facility grounds.
OUTSIDE refers to any location in the
community or off facility grounds.

Yes, INSIDE and OUTSIDE this facility

Yes, INSIDE this facility

Yes, OUTSIDE this facility
No, ongoing counseling is
not provided ➔ Go to Question 11 on page 11

Which forms of ongoing COUNSELING for
mental health problems are provided by a
COUNSELOR?
Mark (X) all that apply.
01

Individual counseling

Line-of-sight supervision

Group counseling

Special clothing to identify young persons as at risk
for suicide

Family counseling

Other – Specify

Special clothing designed to prevent suicide attempts

Restraints used to prevent suicide attempts

Removal of personal items that may be used to
attempt suicide

Removal from the general population

Other – Specify

Page 10

FORM CJ-15 (10-23-2022)

Section 2 – MENTAL HEALTH SERVICES – Continued
11.

Are ANY young persons evaluated or appraised
by a MENTAL HEALTH PROFESSIONAL at a
location INSIDE or OUTSIDE this facility?

14a.

Evaluations and appraisals are conducted by mental
health professionals to diagnose or to identify mental
health needs.

Is ongoing THERAPY for mental health
problems provided to young persons by a
MENTAL HEALTH PROFESSIONAL INSIDE
or OUTSIDE this facility?
Mental health professionals are limited to:
● psychiatrists
● psychologists with at least a Master’s
degree in PSYCHOLOGY
● social workers with at least a Master’s
degree in SOCIAL WORK (MSW, LCSW)

Mental health professionals are limited to:
● psychiatrists
● psychologists with at least a Master’s
degree in PSYCHOLOGY
● social workers with at least a Master’s
degree in SOCIAL WORK (MSW, LCSW)

01
02

Yes, INSIDE and OUTSIDE this facility
Yes, INSIDE this facility
Yes, OUTSIDE this facility

01
02

12.

➔

Go to Question 14a

03
04

When are young persons evaluated or
appraised by a MENTAL HEALTH
PROFESSIONAL?

Which forms of ongoing THERAPY for mental
health problems are provided by MENTAL
HEALTH PROFESSIONALS?
Mark (X) all that apply.

Mark (X) all that apply.

Individual therapy

Within less than 24 hours

Group therapy

Between 24 hours and less than 7 days after
arrival

Family therapy

Other – Specify

Seven or more days after arrival

Other – Specify

c.
13.

Yes, INSIDE and OUTSIDE this facility
Yes, INSIDE this facility
Yes, OUTSIDE this facility
No, ongoing THERAPY is
not provided ➔ Go to Question 15

Which young persons are evaluated or
appraised by a MENTAL HEALTH
PROFESSIONAL?

Which of the following best describes this
facility policy on providing THERAPY by a
MENTAL HEALTH PROFESSIONAL INSIDE or
OUTSIDE this facility?
Mark (X) ONLY ONE response.

Mark (X) all that apply.

All young persons receive some therapy at
some point during their stay

ALL young persons are evaluated or appraised
by a MENTAL HEALTH PROFESSIONAL?

Young persons receive therapy only as
needed on a case-by-case basis

Young persons who come directly from home,
rather than from another facility

Other – Specify

Young persons who are ordered by the court
to get an evaluation

Young persons whom staff identify as needing
an evaluation

Young persons known to have mental health
problems

Young persons for whom no mental health
record is available

Other young persons not listed above –
Specify

FORM CJ-15 (10-23-2022)

15.

Do MEDICAL health professionals INSIDE or
OUTSIDE this facility prescribe and/or
monitor psychotropic medication for young
persons assigned beds here?
01

Yes, INSIDE and OUTSIDE this facility

Yes, INSIDE this facility

Yes, OUTSIDE this facility

No, psychotropic medications are not prescribed

Page 11

Section 2 – MENTAL HEALTH SERVICES – Continued
16a.

Are there one or more special living/sleeping
unit(s) in this facility reserved just for young
persons with mental health problems that are
separate from other living/sleeping units?
01

Yes

➔

18.

Go to Question 17a

Do any of these special living/sleeping units
reserved just for young persons with mental
health problems differ from the other
living/sleeping units in –

19a.

Mark (X) all that apply.

17a.

Are there one or more special living/sleeping
units reserved just for sex offenders that are
separate from other living/sleeping units?
01

Yes

Upon a young person’s departure from this
facility, is information regarding their mental
health status, services and/or needs
communicated to the young persons’ new
placement or residence?

average length of stay?

Yes

physical security and/or monitoring of young
persons?

number of staff per young persons?

type of treatment program?

characteristics of young persons?

specialized criteria for staff selection?

specialized curriculum of treatment for the
residents of these units?

Other? – Specify

Is there a specialized SEX OFFENDER
treatment program located inside this
facility?
01

Yes

➔

Go to Question 18

Are any of the following provided to young
persons charged with or adjudicated for a sex
offense?

➔

Go to Section 3 on page 13

For which young persons is this information
shared?
Mark (X) all that apply.
01

All young persons that depart from
the facility ➔ Go to Section 3 on page 13

Young persons being placed in other juvenile justice
facilities, including halfway houses, shelters or other
transition homes

Young persons returning to the community under
juvenile justice supervision through probation,
parole, or aftercare

Young persons returning to the community (their
homes, independent living, foster care, or another
type of guardian’s care) without further juvenile
justice supervision
Young persons being placed in adult criminal
justice facilities (prisons, jails)

05
06

Young persons going to another living or
placement situation – Please explain

Mark (X) all that apply.

Page 12

A curriculum of treatment designed specifically
for sex offenders

Individual therapy/counseling specifically for
sex offenders

Group therapy in which all members of the
group are sex offenders

Family therapy/counseling specifically for sex
offenders

Other – Specify

FORM CJ-15 (10-23-2022)

Section 3 – EDUCATIONAL SERVICES
1.

After arrival in this facility, are ANY young
persons evaluated to determine their
educational grade levels and their educational
needs at a location either INSIDE or OUTSIDE
this facility?
01

Yes

➔

Go to Question 5

After arrival in this facility, when are young
persons evaluated to determine their
educational grade level?
Mark (X) all that apply.

Within less than 24 hours after arrival

Between 24 hours and less than 7 days after
arrival

Seven or more days after arrival

Other – Specify

Which of the following methods are used to
evaluate young persons to determine their
educational grade levels and their
educational needs?
Mark (X) all that apply.

Review of previous academic records

Interview with an education specialist

Administration of one or more written or
computerized tests

Interview with an intake or admissions
counselor

Interview with guidance counselor

Other – Specify

As part of the DISCHARGE process from this
facility, are ANY young persons evaluated to
determine their educational grade levels and
their educational needs?
01

Yes

➔

Go to NOTE F on page 14

Which young persons are evaluated to
determine their educational grade levels and
their educational needs as part of the
DISCHARGE process from this facility?
Mark (X) all that apply.
01

ALL young persons are
evaluated ➔ Go to NOTE F on page 14

Young persons going home or to live on their
own

Young persons who have been at this facility
long enough to demonstrate a change in
academic performance

Young persons who have not yet earned a
high school diploma

Young persons who have not yet earned a
GED

As many young persons as the educational
specialists have time to evaluate

Other – Specify

Which young persons are evaluated to
determine their educational grade levels and
their educational needs?
Mark (X) all that apply.
01

ALL young persons are
evaluated ➔ Go to Question 5

Young persons who come directly from home,
rather than from another facility

Young persons whom the staff identify as
needing an assessment

Young persons for whom no educational
record is available

Young persons with known educational
problems

Other young persons not listed above –
Specify

FORM CJ-15 (10-23-2022)

Page 13

Section 3 – EDUCATIONAL SERVICES – Continued

NOTE
F

7a.

Questions 7 through 9 ask about educational
services provided either INSIDE and/or
OUTSIDE this facility. INSIDE this facility
refers to any location on the facility grounds.
OUTSIDE this facility refers to any location
in the community or off facility grounds.

Which of the following educational services
are provided to young persons assigned beds
here at a location either INSIDE or OUTSIDE
this facility?
Mark (X) all that apply.
01

Elementary-level education

Middle school-level education

High school-level education

Special education

GED preparation

GED testing

Yes, provided both INSIDE and OUTSIDE this
facility

Post-high school education or post-high school
correspondence courses

Vocational/technical education

Yes, provided INSIDE this facility

Life skills training

Yes, provided OUTSIDE this facility

Other – Specify

No, educational services are not provided to
young persons while assigned beds here

Do ANY young persons assigned beds here
attend school or receive teacher instruction
at a location either INSIDE or OUTSIDE this
facility?
Mark (X) ONLY ONE response.
01
02

Go to Section 4 on page 16

Which young persons attend school or receive
teacher instruction?

9a.

Mark (X) all that apply.

Page 14

ALL young persons are required to
attend school or receive teacher
instruction ➔ Go to Question 8

Those young persons who have not completed
high school or their GED

Those young persons with special needs for
remedial education

Those young persons who have been in the facility
long enough to receive educational services

Those young persons who are required by the state
to attend school because of their age

Those young persons assigned beds in special
living/sleeping units –Specify unit type

Other young persons not listed above –
Specify

How many hours per WEEK do young
persons attend school or receive teacher
instruction during the scheduled academic
school year at a location either INSIDE or
OUTSIDE this facility?
INSIDE
OUTSIDE
Instructional
hours per WEEK

How many months per YEAR do young
persons assigned beds attend school or
receive teacher instruction at a location
either INSIDE or OUTSIDE this facility?
INSIDE

OUTSIDE

Instructional
months per YEAR

FORM CJ-15 (10-23-2022)

Section 3 – EDUCATIONAL SERVICES – Continued
10a.

Upon a young person’s departure from this
facility, is information regarding their
educational status, services and/or needs
communicated to the young persons’ new
placement or residence?
01

Yes

➔

Go to Section 4 on page 16

For which young persons is this information
shared?
Mark (X) all that apply.
01

All young persons that depart from
the facility ➔ Go to Section 4 on page 16

Young persons being placed in other juvenile
justice facilities, including halfway houses,
shelters or other transition homes

Young persons returning to the community under
juvenile justice supervision through probation,
parole, or aftercare

05
06

Young persons going to another living or
placement situation – Please explain

FORM CJ-15 (10-23-2022)

Page 15

Section 4 – SUBSTANCE ABUSE SERVICES
1a.

After arrival in this facility, are ANY young
persons evaluated to determine whether
they have substance abuse problems?
Substance abuse problems include problems with drugs
and/or alcohol.

Yes

➔

When are young persons FIRST evaluated to
determine whether they have substance abuse
problems?
Mark (X) all that apply.
01

Within less than 24 hours after arrival

Between 24 hours and less than 7 days after
arrival

Seven or more days after arrival

Other – Specify

Go to Question 4a

Which of the following methods are used
to evaluate persons after arrival in this
facility to determine whether they have
substance abuse problems?
Mark (X) all that apply.

3a.

Visual observation

Standardized self-report instruments, such as
the SASSI, JASI, ACDI, ASI

Self-report check list inventory which asks
about substance use and abuse

A staff-administered series of questions which
asks about substance use and abuse

None of these methods are used

Other – Specify

Are ALL young persons evaluated after
arrival in this facility to determine whether
they have substance abuse problems?
01

Yes ➔

➔

Go to Question 4a
Continue with Question 3b

After arrival in this facility, which young
persons are evaluated for substance abuse
problems?
Mark (X) all that apply.

4a.

Young persons charged with or adjudicated for
a drug or alcohol-related offense

Young persons identified by the court or a
probation officer as potentially having
substance abuse problems

Young persons identified by facility staff as
potentially having substance abuse problems

Other young persons not listed above – Specify

Are ANY young persons required to provide urine FOR DRUG ANALYSIS after arrival IN
THIS FACILITY?
01

Yes ➔ Continue with Question 4b

➔

Go to NOTE G on page 17

Which statements below describe the circumstances under which young persons are required to
provide urine INSIDE this facility FOR DRUG ANALYSIS? Mark (X) all that apply.

PERSONS
PROVIDING URINE
SAMPLE

CIRCUMSTANCES OF TESTING
Each
time
young
After initial
When drug use is
At randomly
reenter the
arrival in this facility persons
suspected or drug
facility during their scheduled times
is present
stay
(1)

a. Young persons who are suspected
of recent drug or alcohol use

b. Young persons with substance
abuse problems
c. ALL young persons assigned beds
here
Page 16

(2)

(3)

(4)

At the request of
the court or
probation officer
(5)

FORM CJ-15 (10-23-2022)

Section 4 – SUBSTANCE ABUSE SERVICES – Continued

NOTE
G

Questions 5 through 9 ask about substance
abuse services provided at a location either
INSIDE or OUTSIDE this facility. INSIDE
refers to any location on the facility grounds.
OUTSIDE refers to any location in the
community or off facility grounds.

Mark (X) all that apply.

IMPORTANT INSTRUCTIONS
Substance abuse services include:
● developing a substance abuse treatment
plan
● assigning a case manager to oversee
substance abuse treatment
● assigning young persons to special living
units just for those with substance abuse
problems
● ongoing substance abuse therapy or
counseling
● substance abuse education
Substance abuse treatment professionals
are limited in this census to:
● CERTIFIED substance abuse or
addictions counselors
● psychiatrists
● psychologists with at least a Master’s
degree in PSYCHOLOGY
● social workers with at least a Master’s
degree in SOCIAL WORK (MSW, LCSW)

Yes, provided both INSIDE and OUTSIDE this facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, this facility does not provide
substance abuse services ➔ Go to Section 5
on page 19

FORM CJ-15 (10-23-2022)

Substance abuse education

Assignment of a case manager to oversee
substance abuse treatment

Development of a treatment plan to specifically
address substance abuse problems

Special living units in which all young persons have
substance abuse offenses and/or problems

None of these services are offered

Which of the following self-led, self-help
groups are provided INSIDE or OUTSIDE
this facility?
01

8a.

Alcoholics Anonymous

Narcotics Anonymous

Other – Specify

None of these are provided

Is ongoing COUNSELING for substance
abuse problems provided to young persons
INSIDE or OUTSIDE this facility by a
COUNSELOR who is NOT a substance abuse
treatment professional?
Counselors who are NOT substance abuse
treatment professionals are:
● persons with a Master’s degree in a field other
than psychology or social work
● persons whose highest degree is a Bachelor’s
in any field

Do ANY young persons assigned beds here
receive substance abuse services INSIDE or
OUTSIDE this facility other than urinalysis or a
substance abuse screening?
01

Mark (X) all that apply.

Counselors who are NOT substance abuse
treatment professionals are limited to:
● persons with a Master’s degree in a field
other than psychology or social work
● persons whose highest degree is a
Bachelor’s in any field

Which of the following SUBSTANCE ABUSE
services are provided INSIDE or OUTSIDE this
facility?

Yes, provided both INSIDE and OUTSIDE this facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, ongoing COUNSELING for
substance abuse problems is not
provided ➔ Go to Question 9a on page 18

Which forms of ongoing COUNSELING for
substance abuse problems are provided
INSIDE or OUTSIDE this facility to young
persons by a COUNSELOR who is NOT a
substance abuse treatment professional?
Mark (X) all that apply.
01

Individual counseling

Group counseling

Family counseling

None of these are provided

Page 17

Section 4 – SUBSTANCE ABUSE SERVICES – Continued
9a.

Is ongoing THERAPY for substance abuse
problems provided to young persons INSIDE
or OUTSIDE this facility by a SUBSTANCE
ABUSE TREATMENT PROFESSIONAL?
Substance abuse treatment professionals are
limited to:
● CERTIFIED substance abuse/addictions
counselors
● psychiatrists
● psychologists with at least a Master’s degree
in psychology
● social workers with a Master’s degree in
SOCIAL WORK (MSW, LCSW)

Yes, provided both INSIDE and OUTSIDE this facility

Yes, provided INSIDE this facility

Yes, provided OUTSIDE this facility

No, ongoing THERAPY for
substance abuse problems is not
provided ➔ Go to Section 5 on page 19

Which forms of ongoing THERAPY for
substance abuse problems are provided
INSIDE or OUTSIDE this facility to young
persons by a SUBSTANCE ABUSE
TREATMENT PROFESSIONAL?
Mark (X) all that apply.

Individual therapy

Group therapy

Family therapy

None of these are provided

10a.

Upon a young person’s departure from this
facility, is information regarding their
substance abuse status, services and/or
needs communicated to the young persons’
new placement or residence?
01

Yes

➔

Go to Section 5 on page 19

For which young persons is this information
shared?
Mark (X) all that apply.
01

All young persons that depart from
the facility ➔
Go to Section 5 on page 19

Young persons being placed in other juvenile
justice facilities, including halfway houses,
shelters or other transition homes

Young persons returning to the community under
juvenile justice supervision through probation,
parole, or aftercare

05
06

Young persons going to another living or
placement situation – Please explain

Which of the following best describes this
facility policy on providing ongoing therapy for
substance abuse problems INSIDE or
OUTSIDE this facility to persons by a
SUBSTANCE ABUSE TREATMENT
PROFESSIONAL?
Mark (X) ONLY ONE response.

Page 18

All young persons receive specialized therapy
or counseling for substance abuse problems

Young persons receive specialized therapy or
counseling for substance abuse problems only
as needed on a case-by-case basis

Other – Specify

FORM CJ-15 (10-23-2022)

Section 5 – THE LAST MONTH
IMPORTANT INSTRUCTIONS

The following items ask you to answer questions
about different events that may have occurred at this
facility over a 30-day period.

Mechanical restraints include handcuffs, leg cuffs,
waist bands, leather straps, restraining chairs, strait
jackets or other mechanical devices

The 30-day REFERENCE PERIOD for this section
covers the time between the beginning of the day,
September 1, 2022 and the end of the day on
September 30, 2022.

During the month of September 2022, were
there ANY UNAUTHORIZED DEPARTURES of
any young persons who were assigned beds at
this facility?
An "unauthorized departure" includes any incident in
which a young person leaves without staff permission
or approval for more than 10 minutes from:
● The physical security perimeter of the facility
● The mandatory supervision of a staff member when
there is no physical security
● The mandatory supervision of transportation staff
● Any other approved area
01
02

2a.

If the facility staff ONLY used mechanical restraints
during transportation to and from this facility answer NO.
01
02

Yes
No ➔

Yes
No

During the month of September 2022, were
ANY of the young persons assigned beds here
locked for more than four hours alone in an
isolation, seclusion, or sleeping room to
regain control of their unruly behavior?
Answer NO if:
● Young persons were locked in their sleeping
rooms as part of the facility routine
OR
● Young persons were locked in their rooms
ONLY for purposes of quarantine, suicide
watch, facility-wide lockdown, or
self-requested seclusion

Yes
No

During the month of September 2022, were
ANY young persons assigned beds at this
facility transported to a hospital emergency
room by facility staff, transportation staff, or
by an ambulance?
01

During the month of September 2022, were
ANY of the young persons assigned beds here
restrained by facility staff with a mechanical
restraint?

01
02

Yes
No

Go to Question 3

For what reason(s) were the young persons
transported to a hospital emergency room
DURING THIS 30 DAY PERIOD in September?
Mark (X) all that apply.
01
02
03

05
06
07
08
09

Sports-related injury
Work or chore-related injury
An injury that resulted from interpersonal conflict
between one or more young persons, not
including a sports-related injury
An injury that resulted from interpersonal conflict
between a young person and a non-resident
(including staff, visitors, or persons from the
community).
Illness
Pregnancy complications
Labor and delivery
Suicide attempt
A non-emergency injury or illness that occurred
when no physical health professional was available
at the facility or on call
A non-emergency injury or illness that
occurred when no doctor’s appointment could
be obtained in the community
Other – Specify

FORM CJ-15 (10-23-2022)

Page 19

Section 5 – THE LAST MONTH – Continued
5a.

During the month of September 2022 were
there any instances in which this facility was
unable to obtain PHYSICAL HEALTH CARE (at
locations either inside or outside of this
facility) for any young persons with a physical
health complaint or need for physical health
care (both urgent and non-urgent)?

During the month of September 2022 were
there any instances in which this facility was
unable to secure MENTAL HEALTH CARE (at
locations either inside or outside of this
facility) for any young persons with a mental
health complaint or need for mental health
care (both urgent and non-urgent)?

Yes

No, this facility does not provide or broker physical
health care services (except through contacting
emergency services like
ambulances) ➔ Go to Question 6a

No, this facility does not provide or broker mental
health care services (except through contacting
emergency services like
ambulances) ➔ Go to Question 7a on page 21

No, there were no such
instances ➔ Go to Question 6a

No, there were no such
instances ➔ Go to Question 7a on page 21

What reasons prevented PHYSICAL HEALTH
CARE from being secured for young persons
in need?
Mark (X) all that apply.

Page 20

6a.

What reasons prevented MENTAL HEALTH
CARE from being secured for young persons
in need?
Mark (X) all that apply.

Long-term shortages of physical health care
staffing at this facility

Long-term shortages of mental health care
staffing at this facility

Short-term, temporary shortages of physical health
care staffing at this facility

Short-term, temporary shortages of mental health
care staffing at this facility

Shortages, temporary interruptions in, or absence
of contracts with physical health care providers in
the community

Shortages, temporary interruptions in, or absence
of contracts with mental health care providers in
the community

Shortages in line staff or other direct care staff to
fill in for staff who accompany young persons to
health care services

Shortages in line staff or other direct care staff to
fill in for staff who accompany young persons to
mental health care services

Shortages in transportation staff or vehicles

Single or multiple instances of facility lock downs
or other security issues that prevented health
care “services as usual” from occurring for all
young persons in the facility or all young persons
in specific units or wings of this facility

Single or multiple instances of facility lock downs
or other security issues that prevented mental
health care “services as usual” from occurring for
all young persons in the facility or all young
persons in specific units or wings of this facility

Single or multiple instances of security risks for
individual young persons that prevented health
care “services as usual” from occurring

Single or multiple instances of security risks for
individual young persons that prevented mental
health care “services as usual” from occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

FORM CJ-15 (10-23-2022)

Section 5 – THE LAST MONTH – Continued
7a.

During the month of September 2022 were
there any instances in which this facility was
unable to secure EDUCATIONAL
INSTRUCTION (at locations either inside or
outside of this facility) for any young persons
who are required by state statute to receive
educational instruction?

8a.

NOTE: Do not consider planned breaks from
educational instruction (such as summer
recess or religious holidays) as an inability to
provide educational instruction.

Yes

No, this facility does not provide, broker, or
arrange through public schools in the
community any educational
instruction ➔ Go to Question 8a

No, there were no such
instances ➔ Go to Question 8a

During the month of September 2022 were
there any instances in which this facility was
unable to secure SUBSTANCE ABUSE
SERVICES (at locations either inside or
outside of this facility) for any young persons
with a substance use or abuse complaint or
need for substance abuse services (both
urgent and non-urgent)?
01

Yes

No, this facility does not provide or broker
substance abuse services (except through
contacting emergency services like
ambulances) ➔ Go to section 6 on page 22

No, there were no such
instances ➔ Go to section 6 on page 22

What reasons prevented SUBSTANCE ABUSE
SERVICES from being secured for young
persons in need?
Mark (X) all that apply.

What reasons prevented EDUCATIONAL
INSTRUCTION from being secured for young
persons in need?
Mark (X) all that apply.

Long-term shortages of substance abuse service
staffing at this facility

Short-term, temporary shortages of substance
abuse service staffing at this facility

Shortages, interruptions in, or absences of contracts
with substance abuse service providers in the
community

Long-term shortages in educational instructors at
this facility

Short-term, temporary shortages of educational
instructors at this facility

Shortages, interruptions in, or absences of contracts
with educational instruction service providers in the
community

Shortages in line staff or other direct care staff to
fill in for staff who accompany young persons to
substance abuse services

Shortages in transportation staff or vehicles

Shortages in line staff or other direct care staff to
fill in for staff who accompany young persons to
educational instruction

Shortages in transportation staff or vehicles

Single or multiple instances of facility lock downs
or other security issues that prevented substance
abuse “services as usual” from occurring for all
young persons in the facility or all young persons
in specific units or wings of this facility

Single or multiple instances of facility lock downs
or other security issues that prevented
educational “instruction as usual” from occurring
for all young persons in the facility or all young
persons in specific units or wings of this facility

Single or multiple instances of security risks for
individual young persons that prevented
substance abuse “services as usual” from
occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

Single or multiple instances of security risks for
individual young persons that prevented
educational “instruction as usual” from occurring

Planned and/or unplanned requirements to
appear before the court or to meet with legal
counsel

Other reasons – Specify

FORM CJ-15 (10-23-2022)

Page 21

Section 6 – THE LAST YEAR
IMPORTANT INSTRUCTIONS
Questions 1 through 3 ask about deaths of young persons at locations either INSIDE and/or OUTSIDE this
facility during the period between October 1, 2021 and September 30, 2022.
INSIDE this facility refers to any location on the facility grounds.
OUTSIDE this facility refers to any location in the community or off facility grounds.

During the YEAR between October 1, 2021 and September 30, 2022, did ANY young persons die
while assigned a bed at this facility at a location either INSIDE or OUTSIDE of this facility?
01

Yes

➔

Go to Section 7 on page 23

How many young persons died while assigned beds at this facility during the year between
October 1, 2021 and September 30, 2022?
Person(s)

What was the cause of death, location of death, age, sex, race, date of admission to the facility,
and date of death for each young person who died while assigned a bed at this facility?

a. Cause of death
1 – Illness/natural causes
(excluding AIDS)
2 – Injury suffered prior to
placement here
3 – AIDS
4 – Suicide
5 – Homicide or manslaughter
by another resident
6 – Homicide or manslaughter
by non-resident(s)
7 – Accidental death
8 – Coronavirus (COVID-19)
9 – Other – Specify in box ➔
b. Location of death
1 – Inside this facility
2 – Outside this facility

Young person 1

Young person 2

Young person 3

(1)

(2)

(3)

Code

c. Age at death (in years)
d. Sex
1 – Male
2 – Female
e. Race
1 – White, not Hispanic origin
2 – Black or African American,
not of Hispanic origin
3 – Hispanic or Latino
4 – American Indian/
Alaskan Native
5 – Asian
6 – Native Hawaiian or other
Pacific Islander
8 – Other – Specify in box ➔
f. Date of admission to
facility (mm/dd/yyyy)
g. Date of death
(mm/dd/yyyy)

Page 22

FORM CJ-15 (10-23-2022)

Section 7 – GENERAL INFORMATION
1a.

Are there any other juvenile residential facilities located within the same building or on the
same campus as the facility being reported on here?
01

Yes

➔

Go to Note H below

How many OTHER juvenile residential facilities are located within the same building or on
the same campus as the facility being reported on here?

Juvenile residential facilities

Does the facility being reported on here share any of the following with the other facilities
located in the same building or on the same campus?
Mark (X) all that apply.
01
02
03
04
05
06
07
08
09
10
11

The same agency affiliation
The same mailing address
The same on-site administrators
One or more staff directly caring for the young persons
One or more security staff
The same school rooms
The same infirmary
The same food services
The same dining room
The same laundry services
None of the above services are shared
Thank you for completing this questionnaire. If you would like to give us any comments on this
form, please write them at the bottom of this page or attach another sheet.

NOTE
H

Please make a copy of this questionnaire for your records so that if we need to contact you about
a response, you will be able to refer to your copy.
Please mail the completed form in the enclosed postage-paid envelope to –
U.S. Census Bureau
P.O. Box 5000
Jeffersonville, IN 47199–5000
ERD/JRFC
or FAX toll free to: 1–888–262–3974.

Comments

FORM CJ-15 (10-23-2022)

Page 23

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File Modified	2022-05-19
File Created	2022-04-15