Arrest-Related Death Incident Report (Page 3 of 4) in pdf

Print Form

Reset Form

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

1. What was the decedent’s name?

10. What was the reason for the initial contact between the

decedent and law enforcement personnel? (Mark only one)

_______________________, ______________________, ___

Last

First

M.I.

Civilian request for response to criminal or suspicious

activity, specify reason for request:

2. What was the time and date of death?

_____________________________________________

____ : ____

Month: ____Day: ____ , 2013

Civilian request for medical, mental health, or welfare

assistance, specify reason for request:

3. What law enforcement agency was involved with the death?

_____________________________________________

Routine patrol/on-view (other than traffic stop), specify

Agency name: ____________________________________

observed behavior:

Check if multiple law enforcement agencies responded

_____________________________________________

Traffic/vehicle stop, specify reason for stop:

Agency ORI: _____________________________________

_____________________________________________

Agency ORI unknown

Warrant service, specify charge:

_____________________________________________

4. Where did the event causing the death occur?

Other reason for contact, specify reason:

Street Address: ___________________________________

_____________________________________________

Unknown

City, State, Zip: ___________________________________

11. At any time during the incident, did the decedent

5. What location category best describes where the event

Yes No Unknown

causing the death occurred? (Mark only one)

Make suicidal statements ..............................

.....

.........

Residence/home

Barricade self or initiate standoff ...................

.....

.........

Law enforcement facility

Verbally threaten other(s) ..............................

.....

.........

Business, specify type: __________________________

Resist being handcuffed or arrested .............

.....

.........

Roadway/highway/street/sidewalk

Attempt to escape/flee from custody ............

.....

.........

Parking lot/garage

Attempt to grab, hit, or kick officer(s) ............

.....

.........

Field/woods/lake/waterway/beach

Attempt to gain possession of officer’s

Other, specify: __________________________________

weapon .....................................................

.....

.........

Unknown

Gain possession of officer’s weapon ............

.....

.........

6. What was the decedent’s sex?

12. At any time during the incident, did the decedent display or

Male

use a weapon?

Female

Yes, mark all that apply:

Displayed firearm without discharge

7. What was the decedent’s date of birth (DOB)?

Discharged firearm

____/____/______ or age at death if DOB unknown _____

Displayed other weapon, specify weapon displayed:

__________________________________________

8. What was the decedent’s ethnic origin? (Mark only one)

Used other weapon, specify weapon used:

Hispanic or Latino

__________________________________________

Not Hispanic or Latino

Used vehicle as a weapon

Unknown

9. What was the decedent’s race? (Mark only one)

American Indian or Alaska Native

13. At any time during the incident, did the decedent attempt

Asian

to injure or injure others?

Black or African American

Yes, mark all that apply:

Native Hawaiian or Other Pacific Islander

Fatally injured law enforcement personnel

White

Non-fatally injured law enforcement personnel

Two or more races

Attempted to injure law enforcement personnel

Unknown

Fatally injured civilian(s)

Non-fatally injured civilian(s)

Attempted to injure civilian(s)

Unknown

Arrest-Related Death Incident Report Page 3

Related Articles

Related forms

Related Categories