Us Doj Deaths in Custody Report Form Nps 4a 2007
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OMB No. 1121-0249: Approval Expires 06/30/2009 U.S. DEPARTMENT OF JUSTICE NPS-4A (Addendum) FORM (11-8-2006) BUREAU OF JUSTICE STATISTICS DEATHS IN CUSTODY – 2007 STATE PRISON INMATE DEATH REPORT AND ACTING AS COLLECTION AGENT U.S. DEPT. OF COMMERCE Economics and Statistics Admin. U.S. CENSUS BUREAU Reporting Period (Mark only one) Quarter 1 (January 1 – March 31) Quarter 2 (April 1 – June 30) Quarter 3 (July 1 – September 30) Quarter 4 (October 1 – December 31) State First 2. On what date did the inmate die? Month Day out of period total of as reported on form NPS-4 7. On what date had the inmate been admitted to one of your correctional facilities? 1. What was the inmate’s name? Last Death Number MI Month Day Year 8. For what offense(s) was the inmate being held? Year 2 0 0 7 3. What was the name and location of the correctional facility involved? a. b. c. d. e. 4. What was the inmate’s date of birth? Month Day Year 5. What was the inmate’s gender? 9. What was the inmate’s legal status at time of death? • For persons with more than one status, report the status associated with the most serious offense. 01 02 01 02 Male Female 6. What was the inmate’s race/ethnic origin? Mark ( x ) all that apply. 01 02 03 04 05 06 07 White, not of Hispanic origin Black or African American, not of Hispanic origin Hispanic or Latino American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Additional racial category in your information system – Specify 03 04 Convicted – new court commitment Convicted – returned probation/parole violator Unconvicted Other – Specify 10. Where did the inmate die? 01 02 03 04 05 06 In general housing in the facility or on prison grounds In segregation unit In special medical unit/infirmary within your facility In medical facility outside your facility While in transit Elsewhere – Specify 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 30 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, NW, Washington, DC 20531. Name of deceased inmate ____________________________________________ 11. Did a medical examiner or coroner conduct an evaluation (such as an autopsy, post-mortem exam, or review of medical records) in order to establish an official cause of death? 01 Yes ➔ 11a. Are results available? 01 02 02 No ➔ 11b. Is an evaluation planned? 01 02 Yes – Complete items 12 through 16. No – Skip remaining items; you will be contacted later for these data. Yes – Skip remaining items; you will be contacted later for these data. No – Complete items 12 through 16. 12. What was the cause of death? 01 Illness/natural cause • Exclude AIDS-related and accidental deaths. 14. Had the inmate been receiving treatment for the medical condition after admission to your correctional facilities? • EXCLUDE emergency care provided at time of death. Specify illness/cause Yes 02 03 04 05 Acquired Immune Deficiency Syndrome (AIDS) Alcohol/drug intoxication Accidental injury to self – Describe events Accidental injury by other (e.g., positional asphyxiation during cell extraction) – Describe events 07 08 Suicide Homicide committed by other inmate(s) Other homicide – Describe events 07 08 02 07 08 03 07 08 04 07 08 05 07 08 06 07 08 09 Other causes – Specify causes 02 03 04 02 03 • If multiple medical conditions caused the death, mark "01" if any of the conditions were pre-existing. 01 02 08 09 Pre-existing medical condition Inmate developed condition after admission Could not be determined Not applicable – cause of death was accidental injury, intoxication, suicide, or homicide FORM NPS-4A (11-8-2006) Not applicable – cause of death was accidental injury, intoxication, suicide, or homicide Morning (6 a.m. to noon) Afternoon (noon to 6 p.m.) Evening (6 p.m. to midnight) Overnight (midnight to 6 a.m.) Not applicable – cause of death was illness/natural causes, intoxication, or AIDS-related 16. Where did the incident (e.g., accident, suicide or homicide) take place? 01 13. Was the cause of death the result of a pre-existing medical condition or did the inmate develop the condition after admission? Evaluated by physician/medical staff Had diagnostic tests (e.g., X-rays, MRI) Received medications Received treatment/care other than medications Had surgery Confined in special medical unit 15. When did the incident (e.g., accident, suicide or homicide) causing the inmate’s death occur? 09 09 Don’t know 01 01 06 No 04 05 09 In the inmate’s cell/room In a temporary holding area/lockup In a common area within the facility (e.g., yard, library, cafeteria, day room, recreational area, or workshop) Outside of the prison (e.g., while on work release or on work detail, under community supervision, or in transit) Elsewhere – Specify Not applicable – cause of death was illness/natural causes, intoxication, or AIDS-related Notes