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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