[FBI NIBRS Based Form]
SUPPLEMENTARY HOMICIDE REPORT
This report is authorized by law Title 28, Section 534, United States Code. Your cooperation in using this form to list data pertaining to all homicides reported on
your Return A will assist the FBI in compiling comprehensive, accurate data regarding this important classification on a timely basis. Within 30 days of the homicide
incident, the chief law enforcement officer for an agency must submit a completed form to the Minnesota Bureau of Criminal Apprehension.
Submit Report Online at: https://mnjis.x.state.mn.us Send Questions to:
[email protected] REPORT ONLY ONE INCIDENT PER FORM- Report all homicides for this incident (case#) on this form.
*Agency ORI: *Agency Name:
*Date of Incident: (mm/dd/yyyy) *Incident/Case Number: (8 characters)
Yes No The date given above is the actual incident date of the Homicide, and not the date the incident was reported.
*Was there a death in this incident?
Yes No
Do any of the following apply to any victims of this incident, if so please check the box below.
A Death was from a heart attack or natural
A Death was a suicide Death was due to traffic fatality
causes
Death due to motor vehicular
Accidental Death Not from Negligence manslaughter
If any death is checked above, do not report it on this form. It is not considered a homicide.
*Select Either 1a or 1b Homicide Type and Circumstances.
Murder and Non-negligent Manslaughter Definition: The willful (non-negligent) killing of one
1a. human being by another.
(Includes the reporting of “Justifiable Homicide”)
Argument Assault on Law Enforcement Officer(s) Drug Dealing Mercy Killing
Up to Two Circumstances and
Gangland (Organized Crime Involvement Juvenile Gang Lover's Quarrel Domestic Dispute Unknown
Felony Involved (Circle one)
Rape, Robbery, Burglary, Larceny, Motor Vehicle Theft, Arson, Sex Offenses, Prostitution &
Commercialized Vice, Narcotics/Drug Laws, Gambling, Human Trafficking/Commercial Sex
Other Circumstances Acts, Human Trafficking /Involuntary Servitude, Other Felony
Perpetrator Killed by Law Enforcement Perpetrator Killed by Private Citizen
If “Justifiable Homicide” - check:
Definition: The killing of a perpetrator of a serious criminal offense by a police officer in the line of duty;
or the killing, during the commission of a criminal offense, of the perpetrator by a private citizen.
Negligent Manslaughter Definition: The killing of another person through
1b. negligence, with no willful intent.
Child Playing with Weapon Gun Cleaning Accident Hunting Accident
One Circumstance:
Other Negligent Weapon Handling Other Negligent Killing
*REQUIRED: Provide a Brief Narrative of the Homicide Situation Being Reported (Enter Public Data Only)
*Select One Situation:
A. Single Victim/Single Offender D. Multiple Victims/Single Offender
B. Single Victim/Unknown Offender or Offenders E. Multiple Victims/Multiple Offenders
C. Single Victim/Multiple Offenders F. Multiple Victims/Unknown Offender or Offenders
* Required Fields Page 1 Supplemental Homicide Form -R 1/1/2014
VICTIM/OFFENDER INFORMATION CODES
Age (Victim and Offender) Sex Race Ethnicity
UB = Unborn Fetus - (Victim Only) M = Male W = White H = Hispanic or Latino Origin
NN = Under 24 hours - (Victim Only) F = Female B = Black or African American N = Not of Hispanic or
NB = 1-6 days old - (Victim Only) U = Unknown I = American Indian or Alaska Native Latino Origin
BB = 7-364 days old - (Victim Only) A = Asian U = Unknown
01-98 = Exact age in years P = Native Hawaiian or Other Pacific
99 = 99 years or older Islander
00 = Unknown U = Unknown
Victim of Justifiable Homicide - Circumstances Weapon Used by Offender
A. Victim Attacked Police & That Officer Killed Victim 11 - Firearm 40 - Personal Weapons – hands, fist, feet
B. Victim Attacked Police & Killed by Another Officer(s) 12 - Handgun 50 - Poison
C. Victim Attacked a Civilian 13 - Rifle 60 - Explosives
D. Victim Attempted Flight from a Crime 14 -Shotgun 65 - Fire/Incendiary Device
E. Victim Killed in Commission of a Crime 15 - Other gun 70 - Drugs/Narcotics/Sleeping Pills
F. Victim Resisted Arrest 20 - Knife/Cutting Instrument 85 - Asphyxiation
G. Unable to Determine/Not Enough Information 30 - Blunt Object 90 - Other
35 - Motor Vehicle 95 - Unknown
Complete Information for each victim and each offender of this incident only once. (Use codes above)
*Victim Information: *Offender Information: (Officer age, sex, race, ethn. is private)
Vic Age Sex Race Ethnicity Complete Only for Off Age Sex Race Ethnicity Weapon
Num Justifiable Homicide Num For LE Justifiable Homicide enter an Used
Circumstances “X” for age, sex, race and ethnicity
01 01
02 02
03 03
04 04
05 05
(Attach third page if need to report additional victims, offenders or relationship information for this incident)
VICTIM/OFFENDER RELATIONSHIP CODES
Victim Was : Within Family Victim Was: Outside Family But Known Victim Was: Not Known
SE= Spouse (Husband/Wife) GC=Grandchild AQ=Acquaintance XS=Ex-Spouse RU=Relationship Unknown
CS=Common-Law Spouse IL=In-Law FR=Friend EE=Employee ST=Stranger
PA=Parent (Father/Mother) SP=Stepparent NE=Neighbor ER=Employer VO=Victim was Offender*
SB=Sibling (Brother/Sister) SC=Stepchild BE=Babysit tee (Baby) OK=Otherwise Known *Where all of participants in
CH=Child (Son/Daughter) SS=Stepsibling BG=Boyfriend/Girlfriend HR=Homosexual the incident were victims and
offenders of the same offense
OF=Other CF=Child of Boyfriend / Relationship (double murder, barroom
GP=Grandparent
Family Member Girlfriend brawl)
*Complete relationship information for each victim to each offender. (Use codes above)
Victim # Offender # Relationship Code
01 01 *Prepared by:
Title:
*E-Mail:
*Phone:
Agency Head:
(Ex. 2 victims and 2 offenders would require
4 relationships to be completed
(Attach third page if need to report additional victims, offenders or relationship information for this incident )
* Required Fields Page 2 Supplemental Homicide Form-R 1/1/2014
SUPPLEMENTARY HOMICIDE REPORT (Continued)
Agency Name: Case Number:
Additional victim(s) and/or offender(s) of this incident . (Use codes from previous page)
*Victim Information: *Offender Information:
Vic Age Sex Race Ethnicity Complete Only for Off Age Sex Race Ethnicity Weapon
Num Justifiable Homicide Num Used
Circumstances
06 06
07 07
08 08
09 09
10 10
11 11
12 12
13 13
14 14
Additional relationship information for each victim to each offender.
(Use codes from previous page)
Victim # Offender # *Relationship Code
*Prepared by:
Title:
*E-Mail:
*Phone:
Agency Head:
(Ex. 2 victims and 2 offenders would require
4 relationships to be completed)
*Required Fields Page 3 Supplemental Homicide Form-R 1/1/2014
SUPPLEMENTARY HOMICIDE REPORT (Continued)
Terms/Definitions:
American Indian or Alaskan Native - A person having origins in any of the original peoples of the Americas and maintaining
cultural identification through tribal affiliations or community recognition.
Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American - A person having origins in any of the black racial groups of Africa.
Domestic Dispute (Abuse/Violence) - can be broadly defined as a pattern of abusive behaviors by one or both partners in an
intimate relationship such as marriage, dating, family, friends or cohabitation. Domestic abuse has many forms including
physical aggression (hitting, kicking, biting, shoving, restraining, slapping, throwing objects), or threats thereof; sexual abuse;
emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic
deprivation.
FBI – Federal Bureau of Investigation.
Fetal Deaths – Should be reported based on Minnesota Law, but are not reported to the FBI and not counted for the FBI UCR
Program.
Hispanic Origin – A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture of origin,
regardless of race.
Human Trafficking/Commercial Sex Acts – Inducing a person by force, fraud, or coercion to participate in commercial sex acts,
or in which the person induced to perform such acts(s) has not attained 18 years of age.
Human Trafficking/Involuntary Servitude - Obtaining a person(s) through recruitment, harboring, transportation, or provision,
and subjecting such persons by force, fraud, coercion into involuntary servitude, peonage, debt bondage, or slavery (not to
include commercial sex acts).
Justifiable Homicide – The killing of a perpetrator of a serious criminal offense by a peace officer in the line of duty; or the killing,
during the commission of a serious criminal offense, of the perpetrator by a private individual. Justifiable homicides should be
reported under 1a Murder and Non-negligent Manslaughter on this form.
Mercy Killing – Euthanasia - refers to the practice of ending a life in a manner which relieves pain and suffering.
Murder and Non-negligent Manslaughter – The willful (non-negligent) killing of one human being by another. As a general rule,
any death due to injuries received in a fight, argument, quarrel, assault, or commission of a crime is classified in this category.
Suicides, accidental deaths, assaults to murder, traffic fatalities, and attempted murders are not classified as Murder and Non-
negligent Manslaughter. Situations where a victim dies of a heart attack as a result of a robbery or witnessing a crime do not
meet the criteria for inclusion in this classification.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa or
other Pacific Islands. The term "Native Hawaiian" does not include individuals who are native to the State of Hawaii by virtue of
being born there. Other Pacific Island groups included are Carolinian, Fijian, Kosraean, Melanesian, Micronesian, Northern
Mariana Islander, Palauan, Papua New Guinean, Ponapean (Pohnpelan), Polynesian, Solomon Islander, Tahitian, Tarawa
Islander, Tokelauan, Tongan, Trukese (Chuukese), and Yapese.
Negligent Manslaughter – The killing of another person through negligence, with no willful intent. Included in this offense are
killings resulting from hunting accidents, gun cleaning, children playing with guns, etc. Not included are deaths of persons due
to their own negligence; accidental deaths not resulting from gross negligence; and accidental traffic fatalities.
White - A person having origins in any of the original peoples of Europe, North Africa or Middle East.
UCR – Uniform Crime Reporting is a city, county and state law enforcement program which collects crime statistics from local
law enforcement agencies and submits data to the Minnesota UCR Program. The State UCR Program then submits to the
national UCR Program administered by the FBI.
Page 4 Supplemental Homicide Form-R 1/1/2014
