Canadian Centre for Justice Statistics
Please provide information as of time of the incident for each victim.
See instructions below for items indicated with an asterix (*) or refer to the "Scoring Guide for the Homicide Survey" available on the CCJS Extranet Website.
Exempt from Access Under any Legislation
- Incident file number
- Victim number
- Name of victim
- Surname
- Given name(s)
- Alias; or
- Unknown
- Gender of victim
- Male
- Female
Was the victim pregnant?- Yes
- No
- Unknown
- Unknown
- Date of birth of victim
- Year/Month/Day
- Years; or
- Less than 1 year of age (includes newborn)
- Unknown
- Marital status of victim
- Single (never married)
- Married (legal)
- Common-law /cohabitation
- Divorced
- Separated (legal or informal)
- Widowed
- Unknown;
- Aboriginal origin of victim
- Not collected / released by police force
- Non-aboriginal origin
- North American Indian
- Métis
- Inuit / Eskimo
- Unknown
- Employment status of victim (check one only; if more than one applies, check the response closest to the top of the list)
- Illegal activities(e.g. prostitute, drug dealer, gang member)
- Employed (includes full time, part-time, casual, self-employed)
- Unemployed
- Unknown
- Less than 15 years of age (Go to Question 11)
- Student (Go to Question 11)
- Retired (Go to Question 11)
- Homemaker (Go to Question 11)
- Other - specify (e.g., social assistance, disability (Go to Question 11)
- Occupation of victim (enter most recent occupation or other occupation directly related to the homicide)
- Specify; or
- Unknown
- Victim's death associated with their profession (e.g., police officer, taxi driver, prostitute, drug trafficker, etc.)
- Yes;
- No; or
- Unknown;
- Was this victim randomly selected? *
- Yes;
- No; or
- Unknown
- Victim's previous conviction for criminal activities
- No previous conviction
- Homicide
- Robbery
- Other violent offence
- Property offence
- Drug offence
- Other Criminal Code or Federal / Provincial Statute offence
- Unknown
- Primary method used to cause death
- Shooting
- Stabbing
- Beating / blow(s)
- Strangulation, suffocation, drowning
- Poisoning or lethal injection
- Smoke inhalation, burns (fire, liquid, acid)
- Exposure, hypothermia
- Shaken Baby Syndrome
- Other cause – specify
- Unknown
- Weapon used to kill victim (check one only)
- No weapon used (Go to Question 21)
- Fully automatic firearm
- Sawed-off rifle / shotgun
- Handgun (semi-automatic / revolver)
- Rifle / shotgun
- Firearm-like weapon
- Other firearm - type unknown
- Knife (Go to Question 20)
- Other piercing / cutting instrument (Go to Question 20)
- Club or blunt instrument (Go to Question 20)
- Explosives (Go to Question 21)
- Fire, boiling liquid, acid (Go to Question 21)
- Ligature (e.g., rope, belt, cable) (Go to Question 21)
- Poison, drugs, gas, fumes (Go to Question 21)
- Motor vehicle (Go to Question 21)
- Other weapon –specify (Go to Question 20)
- Other weapon - type unknown (Go to Question 21)
- Hands, feet, etc. (Go to Question 21)
- Unknown (Go to Question 21)
- Was the firearm recovered?
- Yes;
- No (Go to Question 18)
- Unknown
- Status of the recovered firearm
- In possession of owner, loaned /borrowed
- Stolen
- Lost or missing
- Unknown
- Was the firearm registered with the Canadian Firearm Registry?
- Yes (Indicate Certificate number)
- No
- Unknown
- Owner of the firearm
- Chargeable suspect
- Victim
- Other
- Unknown
- Does chargeable suspect possess a valid Firearms License?
- Yes
- No
- Unknown
- Classification of the identified weapon
- Restricted
- Prohibited
- Neither restricted nor prohibited
- Unknown
- Consumption of alcohol, drug or intoxicating substance by victim (check one only)
- No alcohol or drug consumed (Go to Question 23)
- Both alcohol and drug consumption
- Alcohol consumption only
- Drug consumption only (Go to Question 23)
- Consumption of intoxicating substance - inhalant, etc. (Go to Question 23)
- Consumption of intoxicant - type unknown (Go to Question 23)
- Unknown (Go to Question 23)
- Blood-alcohol level of victim (milligrams of alcohol per 100 millilitres of blood)
- Indicate quantity; or
- Unknown
- Victim was first to use or first to threaten to use physical force or violence in this incident
- Yes
- No
- Unknown
- Closest Chargeable Suspect - Victim Relationship * (code the closest relationship between any of the chargeable suspects and this victim)
- Chargeable suspect number (Question 2 on Charged / Suspect-Chargeable Questionnaire) ; or
- No chargeable suspect (End)
Spousal relationship- Husband (legally married)
- Common-law husband
- Separated husband (legal)
- Separated common-law husband
- Divorced husband
- Wife (legally married)
- Common-law wife
- Separated wife (legal)
- Separated common-law wife
- Divorced wife
- Same-sex spouse (legal or common-law)
- Ex-same-sex spouse (separated or divorced)
- Father
- Step-father
- Mother
- Step-mother
- Son
- Step-son
- Daughter
- Step-daughter
- Brother
- Sister
- Other family
- Boyfriend
- Girlfriend
- Same sex relationship
- Extra-marital lover
- Ex-boyfriend /girlfriend
- Other intimate relationship
- Close friend
- Neighbour
- Authority figure*
- Business relationship
- Criminal relationship*
- Casual acquaintance
- Stranger
- Other – specify
- Unknown
Instructions
The investigating officer is the ideal person to complete this form.
*11. Random homicide - A homicide that does not aim to target one specific individual. If solved, it will normally involve the killing of a stranger who is engaging in the normal course of their daily lives or who is "in the wrong place at the wrong time". A homicide may be considered random even if the victim is selected from a pre-determined group as long as all members of the group have an equal chance of being chosen. For example, if a perpetrator is seeking to kill a female child this homicide may be random if all female children were at risk.
24. Authority figure - e.g., teacher, doctor, baby-sitter, priest, etc.
Criminal relationship - refers to a relationship between a prostitute and client, drug trafficker and drug user, etc.
Thank you for your cooperation