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

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Form CJ-11A

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

Name of decedent

18. Where did the death occur? (Mark only one)

14. At any time during the incident, did law enforcement

Law enforcement facility/booking center

personnel

Yes

Unknown

Scene of incident

Fight or struggle with decedent .....................

.....

.........

Dead on arrival at medical facility

Physically restrain decedent

Medical facility following clinical intervention

(e.g., control hold, body compression) ....

.....

.........

Other, specify: ________________________________

Restrain decedent with equipment

Unknown

(e.g., handcuffs, leg shackles) .................

.....

.........

Place decedent in prone position ..................

.....

.........

19. What was the manner of death? (Mark only one)

Natural

Engage in motor vehicle pursuit ....................

.....

.........

Homicide

Engage in foot pursuit ...................................

.....

.........

Accident

Arrest the decedent .......................................

.....

.........

Suicide

Other, specify: __________________ .......

.....

.........

Could not be determined

15. At any time during the incident, did law enforcement

Unknown

personnel use any of the following weapons?

Yes

Unknown

20. What was the cause of death?

Firearm discharge .........................................

.....

.........

Immediate cause:

Conducted energy device (Taser) contact ....

.....

.........

_____________________________________________

Pepper/OC spray, mace dispersion ..............

.....

.........

Secondary causes (if applicable):

Baton/blunt instrument impact ......................

.....

.........

_____________________________________________

Other, specify: __________________ .......

.....

.........

_____________________________________________

16. Did the decedent sustain a fatal injury during the incident?

Yes, mark who caused the fatal injury (Mark only one)

Unknown (skip Item 21 if cause of death is unknown)

Law enforcement personnel

Decedent

21. How was information provided for cause of death (Item 20)

determined? (Mark all that apply)

Other civilian(s)

Death certificate

Autopsy report or medical evaluation

Other source, specify: ___________________________

Unknown

17. If a weapon caused the death, what type of weapon caused

22. Did the autopsy report or medical evaluation indicate the

the death? (Mark only one)

presence of alcohol or of drugs other than alcohol?

Handgun

Yes, mark all that apply:

Rifle/shotgun

Alcohol

Firearm, unspecified

Drug(s) other than alcohol, specify:

Conducted energy device (e.g., Taser)

__________________________________________

Knife/edged instrument

Baton/blunt instrument

Unknown, did not obtain autopsy report or medical

Other weapon, specify: __________________________

evaluation

Vehicle-involved death (i.e., vehicle accident)

Not applicable, weapon or vehicle did not cause death

Unknown

Notes:

______________________________________________________________________________________________________________

Arrest-Related Death Incident Report Page 4

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