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pdfOMB No. 1121-0249 Approval Expires 12/31/2012
U.S. DEPARTMENT OF JUSTICE
NPS-4A (Addendum)
FORM
(10-13-2009)
BUREAU OF JUSTICE STATISTICS
DEATHS IN CUSTODY — 2009
STATE PRISON INMATE DEATH REPORT
AND ACTING AS COLLECTION AGENT
RTI International
Crime, Violence, and Justice
Research Program
Reporting Period (Mark only one.)
State
DRAFT
1.
2.
7.
What was the inmate’s name?
Last
First
Ml
out of period total of ____
as reported on form NPS-4
On what date had the inmate been admitted to
one of your correctional facilities?
Month
Day
Year
On what date did the inmate die?
8.
Month
3.
Death Number ____
Quarter 1 (January 1 — March 31)
Quarter 2 (April 1 — June 30)
Quarter 3 (July 1 — September 30)
Quarter 4 (October 1 — December 31)
Day
Year
2 0 0 9
For what offense(s) was the inmate being held?
a.
b.
What was the name and location of the
correctional facility involved?
c.
d.
4.
Month
5.
e.
What was the inmate’s date of birth?
Day
Year
9.
What was the inmate’s sex?
01 Yes
02 No
08 Don’t know
01 Male
02 Female
6.
Since admission, did the inmate ever stay overnight in a
mental health observation unit or an outside mental
health facility?
What was the inmate’s race/ethnic origin?
01
02
03
04
05
06
White (not of Hispanic origin)
Black or African American (not of Hispanic origin)
Hispanic or Latino
American Indian/Alaska Native (not of Hispanic origin)
Asian (not of Hispanic origin)
Native Hawaiian or Other Pacific Islander (not of
Hispanic origin)
07 Two or more races (not of Hispanic origin)
08 Additional categories in your information system—
Specify
10. Where did the inmate die?
01
02
03
04
05
06
07
08
In general housing in the facility or on prison grounds
In segregation unit
In special medical unit/infirmary within your facility
In special mental health services unit within your facility
In medical center outside your facility
In mental health center outside your facility
While in transit
Elsewhere — Specify
09 Not known
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.
DRAFT
Name of deceased inmate
11. Are the results of a medical examiner’s or coroner’s evaluation (such as an autopsy, post-mortem
exam, or review of medical records) available in order to establish an official cause of death?
01 Yes — Complete items 12 through 16.
02 Evaluation complete, results are pending — Skip remaining items; you will be contacted later for those data.
03 No such evaluation is planned — Complete items 12 through 16.
15. When did the incident (e.g., accident, suicide or
homicide) causing the inmate’s death occur?
12. What was the cause of death?
01 Illness
01
02
03
04
• Exclude AIDS-related deaths.
Specify illness
02 Acquired Immune Deficiency Syndrome (AIDS)
03 Accidental alcohol/drug intoxication — Specific type
Morning (6 a.m. to noon)
Afternoon (noon to 6 p.m.)
Evening (6 p.m. to midnight)
Overnight (midnight to 6 a.m.)
09 Not applicable — cause of death was illness,
intoxication, or AIDS-related
04 Accidental injury to self — Describe events
16. Where did the incident (e.g., accident, suicide
or homicide) take place?
01 In the prison facility or on prison grounds — Specify
05 Accidental injury by other (e.g., vehicular accidents
during transport) — Describe events
a. In the inmate’s cell/room
b. In a temporary holding area/lockup
c. In a common area within the facility (e.g., yard,
06 Suicide (e.g., hanging, knife/cutting instrument,
intentional drug overdose) – Describe events
d.
e.
f.
g.
07 Homicide committed by other inmate(s)
08 Homicide incidental to use of force by staff —
Describe events
h.
09 Other causes — Specify causes
library, cafeteria, day room, recreational area,
or workshop)
In special medical unit/infirmary
In special mental health services unit
In a segregation unit
On death row, special unit awaiting capital
punishment
Elsewhere within prison facility — Specify
02 Outside the prison (e.g., while on work release or
13. Was the cause of death the result of a pre-existing medical
condition or did the inmate develop the condition after
admission?
• If multiple medical conditions caused the death,
mark “01” if any of the conditions were pre-existing.
01
02
08
09
09 Not applicable — cause of death was illness,
intoxication, or AIDS-related
Pre-existing medical condition
Inmate developed condition after admission
Could not be determined
Not applicable — cause of death was accidental
Notes
injury, intoxication, suicide, or homicide
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.
Yes
01
02
03
04
No
07
07
07
07
Don’t know
08 Evaluated by physician/medical staff
08 Had diagnostic tests (e.g. x-rays, MRI)
08 Received medications
08 Received treatment/care other than
medications
05 07 08 Had surgery
06 07 08 Confined in special medical unit
09 Not applicable — cause of death was accidental
injury, intoxication, suicide, or homicide
FORM NPS-4A (10-13-2009)
on work detail, under community supervision,
or in transit)
03 Elsewhere — Specify
Page 2
| File Type | application/pdf |
| File Title | NPS-4A 2009-final.fm |
| Author | sabolw |
| File Modified | 2009-12-18 |
| File Created | 2005-08-26 |