Arrest-Related Death Incident Report printable pdf download

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Form CJ-11A

OMB No. 1121-0249 Approval Expires 12/31/2015

U.S. DEPARTMENT OF JUSTICE

ARREST-RELATED DEATH

BUREAU OF JUSTICE STATISTICS

INCIDENT REPORT, 2013

AND ACTING AS COLLECTION AGENT:

RTI INTERNATIONAL

DATA SUPPLIED BY

Name: __________________________________________________

Title: ____________________________________________________

(__ __ __ ) __ __ __ - __ __ __ __

Agency: _________________________________________________

Telephone:

(__ __ __ ) __ __ __ - __ __ __ __

________________________________________________

Fax:

State: ___________________________________________________

E-mail Address: ___________________________________________

INSTRUCTIONS FOR COMPLETION

• Complete an Incident Report (CJ-11A) for all civilian deaths caused by an event occurring during an interaction with state or local

law enforcement personnel. Report all civilian deaths that occur while the decedent’s freedom to leave is restricted by state or local

law enforcement personnel—including deaths that occur prior to, during, or following an arrest.

• Complete questions 1 through 22 for each arrest-related death in your jurisdiction. Any additional information or a short narrative of

the incident may be provided in the “Notes” section at the end of the CJ-11A.

• Include the decedent’s name on both pages 3 and 4 of the CJ-11A.

• Send the completed CJ-11A by FAX or MAIL to your State Reporting Coordinator (SRC) within 60 days of the arrest-related death.

A national listing of SRCs is located on page 2 of this form. If needed, please contact SRCs directly for a mailing address.

• If no arrest-related deaths occurred in your jurisdiction, you will not need to complete a CJ-11A.

• If you need assistance completing the CJ-11A, please refer to the CJ-11A Question-by-Question Guide or contact the Arrest-Related

Deaths (ARD) Help Desk at

or toll-free at 1-877-475-7039.

WHAT DEATHS SHOULD BE REPORTED?

INCLUDE

EXCLUDE

• All deaths resulting from any use of force by state or local law

• Deaths attributed to federal law enforcement personnel (e.g.,

enforcement personnel.

FBI, DEA).

• All deaths caused by injuries sustained while attempting to

• Any inmate death that occurred in the custody of local jails, state

elude state or local law enforcement personnel or injuries

prisons, state juvenile correctional facilities, or private

incurred after custody had been established.

correctional facilities. These types of deaths should be reported

to the Jails and Prisons data collection component of the Deaths

• All deaths attributed to suicide, alcohol or other drug

in Custody Reporting Program. Please contact Margaret

intoxications, or medical conditions (e.g., cardiac arrest) that

Noonan at 202-307-0765 for additional information.

occur during the process of arrest by or in the custody of state

or local law enforcement personnel.

• Law enforcement personnel killed in the line of duty or in the

course of law enforcement activities.

• All deaths occurring in the custody of state or local law

enforcement personnel responding to a medical or mental

• Any death of a criminal suspect that occurred before the

health assistance or welfare call.

decedent came into contact with law enforcement (e.g., a

decedent with an active arrest warrant who died before law

• All deaths that occur while confined in lockups or booking

enforcement personnel attempted to apprehend him or her).

centers (i.e., facilities from which arrestees are usually

transferred within 72 hours and not held beyond arraignment).

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 60 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, N.W., Washington, DC 20531.

Arrest-Related Death Incident Report

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