LCLE – Death in Custody Reporting Act

Agency Name *

Contact Name *

First

Last

Contact Phone Number *

Contact Email *

Reporting Year *

Select the Reporting Period *

1st Quarter: January 1 - March 31
2nd Quarter: April 1 - June 30
3rd Quarter: July 1 - September 30
4th Quarter: October 1 - December 31

Decedent Information

Please provide the following decedent information. If you have multiple deaths in custody, you will report one at a time.

First Name *

Middle Name

Last Name *

Gender *

1. Male
2. Female
3. Other gender identity

Please Indicate Gender Identity *

Race (Select all that apply) *

Ethnicity *

1. Hispanic, Latino, or Spanish Origin
2. Not of Hispanic, Latino, or Spanish Origin
3. Unknown

Birth Year (YYYY) *

If unknown, please enter "9999"

Date of Death *

Time of Death *

Location of Death - Location Name (if not applicable, enter N/A) *

This could be the name of a facility, place of business, or other designation for the location of death.

Location of Death - Street Address *

Location of Death - City *

Location of Death - State *

Zip Code *

If the event causing the death occurred in any of the following facilities, please indicate the appropriate facility below. If the event causing the death did not occur in one of the facilities listed below, please use the "None of the above" answer choice. *

1. Municipal or county jail
2. State prison
3. State-run boot camp prison
4. Contracted boot camp prison
5. Any state or local contract facility
6. Other local or state correctional facility (to include any juvenile facilities)
7. None of the above

Please list the name of the department or agency that detained, arrested, or was in the process of arresting the deceased. *

Please indicate the manner of death (Mark only one). *

A. Execution
B. Accident
C. Death attributed to use of force by a law enforcement or corrections officer
D. Homicide (e.g., an incident between two or more incarcerated individuals resulting in a death)
E. Natural causes
F. Suicide
G. Unavailable, investigation pending
H. Other

If manner of death is unavailable, please report the agency conducting the investigation and an approximate end date. *

If manner of death is Other, please explain: *

Please provide a brief description of the circumstances leading to the death (e.g., details surrounding an event that may have led to the death, the number and affiliation of any parties involved in an incident, the location and characteristics of an incident, other context related to the death, etc.). *

Program Reports Due	Reporting Period	Quarter
January 10	October 1 – December 31	1st
April 10	January 1 – March 31	2nd
July 10	April 1 – June 30	3rd
October 10	July 1 – September 30	4th