Canadian Centre for Justice Statistics
Policing Services Program
Confidential when completed
Please provide information as of time of the incident for each victim.
See instructions on last page for items indicated with an asterisk ( * ) or refer to the "Scoring Guide for the Homicide Survey".
This information is collected under the authority of the Statistics Act, Revised Statutes of Canada, 1985, Chapter S-19.
Completion of this questionnaire is a legal requirement under this act.
Objective
This survey collects essential data to produce statistics on the incidence and characteristics of homicide offences in Canada. The information is used by federal and provincial policymakers as well as public and private researchers. The data are also widely disseminated by the media for purposes of general public information. The information may also be used by Statistics Canada for other statistical and research purposes.
Confidentiality
Statistics Canada is prohibited by law from releasing any information it collects which could identify any person, business, or organization, unless consent has been given by the respondent or as permitted by the Statistics Act. Statistics Canada will use the information from this survey for statistical purposes.
Record linkages
To enhance the data from this survey and to minimize the reporting burden for respondents, Statistics Canada may combine the information you provide with other survey or administrative data sources.
Instructions
Please return this questionnaire by December 31st, “Collection Year”. Questionnaires may be returned by mail (see address below) or through the Electronic File Transfer system
Correspondence
Statistics Canada
ATTN: Central Reception
200 blvd. de la Technologie
Gatineau, QC J8Z 3H6
Phone: Toll free 1-888-659-8229
Fax: 1-888-883-7999
E-mail: homi-surv@statcan.gc.ca
Fax or e-mail transmission disclosure
Statistics Canada advises you that there could be a risk of disclosure during facsimile or other electronic transmission. However, upon receipt, Statistics Canada will provide the guaranteed level of protection afforded all information collected under the authority of the Statistics Act.
- Incident file number
- Victim number
- Name of victim
- Surname
- Given name(s)
- Alias
- OR
- 9 Unknown
- Gender of victim
- 1 Male
- 2 Female
- Was the victim pregnant?
- 1 Yes
- 2 No
- 9 Unknown
- 9 Unknown
- a. Date of birth of victim
- Year / Month / Day
- Years
OR
000 Less than 1 year of age (includes newborn)
999 Unknown
- Marital status of victim
- 1 Single (never married)
- 2 Married (legal)
- 3 Common-law /cohabitation
- 4 Divorced
- 5 Separated (legal or informal)
- 6 Widowed
- 9 Unknown
- Aboriginal identity of victim
- 00 Not collected / released by police service
- 01 Not an Aboriginal person
- 02 First Nations person (Status or non-Status)
- 03 Métis
- 04 Inuit
- 05 Aboriginal person (group unknown)
- 99 Unknown
- Employment status of victim (check one only; if more than one applies, check the response closest to the top of the list)
- 00 Illegal activities (e.g. prostitute, drug dealer, gang member)
- 01 Employed (includes full time, part-time, casual, self-employed)
- 02 Unemployed
- Not in labour force
- 03 Less than 15 years of age - Go to Question 11
- 04 Student - Go to Question 11
- 05 Retired - Go to Question 11
- 06 Homemaker - Go to Question 11
- 07 Other – specify (e.g., social assistance, disability) - Go to Question 11
- 99 Unknown
- Occupation of victim (enter most recent occupation or other occupation directly related to the homicide)
- Specify
- OR
- 9 Unknown
- Victim’s death associated with their profession (e.g., police officer, taxi driver, prostitute, drug trafficker, etc.)
- 1 Yes
- 2 No
- 9 Unknown
- Was this victim randomly selected? *
- 1 Yes
- 2 No
- 9 Unknown
- Prior to the discovery of this victim, had he or she been reported as a missing person (to you or any other police service)?
- 1 Yes
- 2 No
- 9 Unknown
- Victim’s previous conviction for criminal activities
- 88 No previous conviction
- Most serious conviction
- 01 Homicide
- 02 Robbery
- 03 Other violent offence
- 04 Property offence
- 05 Drug offence
- 06 Other Criminal Code or Federal / Provincial Statute offence
- 99 Unknown
- Source of information (e.g., CPIC, your own information system, etc.)
- Primary method used to cause death
- 01 Shooting
- 02 Stabbing
- 03 Beating / blow(s)
- 04 Strangulation, suffocation, drowning
- 05 Poisoning or lethal injection
- 06 Smoke inhalation, burns (fire, liquid, acid)
- 07 Exposure, hypothermia
- 08 Shaken Baby Syndrome
- 09 Other cause – specify
- 99 Unknown
- Weapon used to kill victim (check one only)
- 88 No weapon used - Go to Question 22
- 01 Fully automatic firearm
- 02 Sawed-off rifle / shotgun
- 03 Handgun (semi-automatic / revolver)
- 04 Rifle / shotgun
- 05 Firearm-like weapon
- 06 Other firearm – type unknown
- 07 Knife - Go to Question 21
- 08 Other piercing / cutting instrument - Go to Question 21
- 09 Club or blunt instrument - Go to Question 21
- 10 Explosives - Go to Question 22
- 11 Fire, boiling liquid, acid - Go to Question 22
- 12 Ligature (e.g., rope, belt, cable) - Go to Question 22
- 13 Poison, drugs, gas, fumes - Go to Question 22
- 14 Motor vehicle - Go to Question 22
- 15 Other weapon – specify - Go to Question 21
- 16 Other weapon – type unknown - Go to Question 22
- 17 Physical force (e.g., hands, feet) - Go to Question 22
- 99 Unknown - Go to Question 22
- Was the firearm recovered?
- 1 Yes
2 No - Go to Question 19
9 Unknown
- 1 Yes
- Status of the recovered firearm
- 0 In possession of owner, loaned / borrowed
- 1 Stolen
- 2 Lost or missing
- 9 Unknown
- Was the firearm registered with the Canadian Firearm Registry?
- 1 Yes - Certificate number
- 2 No
- 8 Not applicable
- 9 Unknown
- Owner of the firearm
- 1 Chargeable suspect
- 2 Victim
- 3 Other
- 9 Unknown
-
Does chargeable suspect possess a valid Firearms License?
- 1 Yes
- 2 No
- 9 Unknown
-
Classification of the identified weapon
- 1 Restricted
- 2 Prohibited
- 3 Neither restricted nor prohibited
- 9 Unknown
-
Consumption of alcohol, drug or intoxicating substance by victim (check one only)
- 8 No alcohol or drug consumed - Go to Question 24
- 1 Both alcohol and drug consumption
- 2 Alcohol consumption only
- 3 Drug consumption only - Go to Question 24
- 4 Consumption of intoxicating substance – inhalant, etc. - Go to Question 24
- 5 Consumption of intoxicant – type unknown - Go to Question 24
- 9 Unknown - Go to Question 24
-
Blood-alcohol level of victim (milligrams of alcohol per 100 millilitres of blood)
- Specify level
- OR
- 999 Unknown
-
Victim was first to use or first to threaten to use physical force or violence in this incident
- 1 Yes
- 2 No
- 9 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)
- Specify chargeable suspect number
- OR
- 88 No chargable suspect - End
- Victim killed by:
- Spousal relationship
- 01 Husband (opposite sex, legally married)
- 02 Common-law husband (opposite sex)
- 03 Seperated husband (opposite sex, legal)
- 04 Seperated common-law husband (opposite sex)
- 05 Divorced husband (opposite sex)
- 06 Wife (opposite sex, legally married)
- 07 Common-law wife (opposite sex)
- 08 Seperated wife (opposite sex, legal)
- 09 Seperated common-law wife (opposite sex)
- 10 Divorced wife (opposite sex)
- 38 Same-sex spouse (legally married)
- 39 Same-sex spouse (common-law)
- 40 Seperated same-sex spouse (legally married)
- 41 Seperated same-sex spouse (common-law)
- 42 Divorced same-sex spouse
- Other family relationship
- 13 Father
- 14 Step-father
- 15 Mother
- 16 Step-mother
- 17 Son
- 18 Step-son
- 19 Daughter
- 20 Step-daughter
- 21 Brother
- 22 Sister
- 23 Other family
- Other intimate relationship
- 24 Boyfriend
- 25 Girlfriend
- 26 Same sex relationship
- 27 Extra-marital lover
- 28 Ex-boyfriend / girlfriend
- 29 Other intimate relationship
- Acquaintance
- 30 Close friend
- 31 Neighbour
- 32 Authority figure *
- 33 Business relationship
- 34 Criminal relationship *
- 35 Casual acquaintance
- 36 Stranger
- 37 Other – specify
- 99 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 or 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.
25. 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