Shooting incidents such as the one at Sandy Hook Elementary School in December 2012 and the one at an Aurora, CO, movie theater in July 2012 have focused attention on federal policy issues in the law enforcement, public health, and education arenas, among others. The Congressional Research Service (CRS) has identified 78 public mass shootings that have occurred in the United States since 1983. These shootings have claimed almost 550 lives according to CRS estimates. How does the death toll tied to public mass shootings compare with figures related to the preeminent threat that federal law enforcement has confronted in the last decade? CRS estimates that since the terrible events of September 11, 2001 (9/11), Al-Qaeda-inspired homegrown terrorists have killed 14 people in two incidents in the United States. Since 9/11, according to CRS estimates, 281 people have died in 38 public mass shootings. Arguably, the comparatively low death toll associated with Al Qaeda-inspired incidents at least partly results from a large-scale federal focus on homeland security and counterterrorism efforts. It is important to caution the reader that, while tragic and shocking, public mass shootings account for few of the murders related to firearms that occur annually in the United States. According to the Federal Bureau of Investigation (FBI, the Bureau), in 2011, firearms were used to murder 8,583 people. To provide further context, over the last two decades, the nation has experienced a general decline in violent crime. In 1992, 1.9 million violent crimes were reported, while 2011 saw 1.2 million. In the same period, the national murder rate dropped from 9.3 to 4.7 per 100,000 inhabitants. As a starting point, this report delves into public mass shootings over the last three decades, exploring the nature of this threat. In its broader discussion of related federal public health and safety issues, the report covers selected policy implications in three areas: law enforcement , public health , and education . While mass shootings may occur in a number of public settings, the education realm is one that has generated concern from policy makers, officials, and the public alike—at least since the 1999 shooting at Columbine High School in Littleton, CO. The tragedy at Sandy Hook Elementary has renewed such concerns for many. In this report, discussion of each of these is further broken down into efforts geared toward prevention —actions intended to reduce the likelihood of shootings. preparedness — planning how to cope with potential shootings. response —structured efforts employed to react to an actual shooting. Policy measures that deal with recovery are also discussed within the context of education and public health initiatives. Recovery entails helping institutions, communities, and individuals cope with the aftermath of a shooting. This report is not intended as an exhaustive review of specific federal programs in these areas. Also, this report does not focus on gun violence or writ large, nor does it discuss gun control policies. This report attempts to refine the relatively broad concept of mass shooting (which could potentially involve a wide variety of actors targeting victims for any number of reasons) into a narrower formulation: public mass shootings. This has been done to focus discussion around a number of violent incidents that lie outside of specific crime issues such as terrorism, drug trafficking, gang activity, and domestic violence that have federal policies, law enforcement structures, and laws tailored in many instances to specifically address them. In order to delineate a workable understanding of public mass shooting for this report, CRS examined scholarly journal articles, monographs, and government reports. These sources discussed a variety of terms such as mass murder, mass shooting, mass killings, massacres, and multiple homicide. Definitions of these terms varied with regard to establishing the number of victims or fatalities involved, the weapons used, the motives of the perpetrator, and the timeframes within which the casualties or injuries occurred. This report defines public mass shootings as incidents occurring in re latively public places, involvin g four or more deaths—not including the shooter(s)—and gunmen who select victims somewhat indiscriminately. The violence in these cases is not a means to an end such as robbery or terrorism . Relatively public places. For this report, public mass shootings happen in relatively public circumstances. Such settings can include schools, workplaces, restaurants, parking lots, public transit, or even private parties that include at least some guests who are not family members of the shooter. Tallying Fatalities. Any definition of mass shootings requires a somewhat arbitrary threshold demarcating the number of victims killed per incident. This report's threshold is based on a definition of mass murder offered by the FBI. An important caveat deserves mentioning. A compilation of incidents based on any such arbitrary threshold may fail to adequately describe the universe of incidents to which educators, public health professionals, and law enforcement have to react and for which they have to prepare. One author has stated that gunmen "injure far more victims than they kill; however, they must certainly be considered mass murderers by obvious intentions of their actions." In the critical early moments of a shooting, police, teachers, and rescue personnel do not necessarily know how many people are injured versus dead. Personnel and resources are initially mobilized in response to a shooting, regardless of the number of fatalities. Indiscriminate Selection of Victims. For this report's definition, a killer's relationship to his or her victims is important. Driven by a desire for revenge and/or power, some killers may target family members or intimate friends. In the incidents described as public mass shootings for this report, the gunmen cannot solely kill such individuals. This particularly rules out cases of domestic violence—instances only involving family members either inside or outside the home—from consideration as public mass shootings. Thus, for this report, the gunmen in public mass shootings somewhat indiscriminately select their victims. For example, a student assailant involved in a public mass shooting plans on killing particular teachers, while simultaneously staging a wider assault on his school. Violence Not a Means to an End. For this report, a public mass shooter's agenda certainly may stem from his specific personal experiences and psychological conditions. However, as implied in the above definition, the shooters who perpetrated the incidents counted in this report did not have broad socio-political objectives, such as using violence to advocate the fall of a regime. Thus, gunmen acting in the name of a terrorist organization or a clearly framed philosophy of hate typically were not considered public mass shooters. Also, shootings largely motivated by criminal profit were not counted. Based on the purpose undergirding the assailant's violence, the following examples do not fit the definition of public mass shooting used for this report. In December 2012, Dwayne Moore was convicted of home invasion, armed robbery , and four counts of first-degree murder in Massachusetts. He reportedly gunned down four victims, including a child, in a September 2010 drug-related incident in Boston, MA. A mass murder that has been widely reported as a hate-motivated incident occurred on the morning of August 5, 2012, when Wade Michael Page shot to death six people at the Sikh Temple of Wisconsin in Oak Creek—near Milwaukee, WI. According to the FBI, police responding to the scene returned fire, wounding Page. He then took his own life by shooting himself. U.S. Army Major Nidal Hasan was charged in a shooting at Fort Hood, TX, on November 5, 2009. The mass murder, which has been described as a terrorist incident , killed 13 and injured more than 40 others. To identify incidents of public mass shootings, CRS reviewed descriptions of mass shooting events found in scholarly journal articles, monographs, lists created by government entities and advocacy organizations, and news accounts. It is important to note that while every effort was made to be thorough in reviewing the sources used, the incidents identified by CRS should not be considered as constituting an exhaustive list of public mass shootings. Readers are also cautioned against tying this report's definition of public mass shootings directly to specific federal policy responses. In other words, the policy responses discussed below are not restricted to preventing or reacting to public mass shootings as defined in this report. For instance, many of the policy measures discussed herein respond to shooting events or threats that could include fewer than four deaths or shooters with specific ideologies and targets. The shooting definition offered in this report is meant to help illustrate the nature and breadth of a threat that lacks an agreed-upon conceptualization among experts, capturing some of the most extreme shooting cases over the last three decades. For many years, mass shootings have been of interest and concern to a variety of experts—including psychologists, sociologists, criminologists, public health experts, policy makers, and students of popular culture—who have written much on the topic. Journalists have tracked such killings for a long time as well. For example, a case involving gunman Howard B. Unruh in September 1949 received national attention. There were over 50 news articles in more than a dozen major newspapers in the United States in the month after the shooting occurred. In what was reported at the time as the largest mass murder in U.S. history, Unruh killed 13 people in a 20-minute-long incident in Camden, NJ. He shot people he knew as well as strangers. His victims included three children. All of this interest in such shootings has produced a wide variety of terms and concepts that address an assortment of issues. Categorizing types of murder—and mass shootings, more narrowly—can be tricky. In many cases, individual incidents involving assailants who kill one, two, or three people are described as single, double, or triple murder. However, when the number of victims rises or the case involves complicating circumstances such as the killer assailing individuals in different locations or a string of murders committed over a period of days, months, or years, efforts to define and understand murder can grow much more difficult. Most scholarly and expert sources suggest that mass shootings are rare violent crimes. One study has described them as "very low-frequency and high intensity event[s]." The 78 public mass shootings between 1983 and 2012 that CRS has identified claimed 547 lives (see Figure 1 ). Public mass shootings, as defined by this report, can be viewed as part of the larger issue of "multiple murder." A lexicon has emerged since the 1980s to describe instances of multiple murder. Qualitatively broader than cases of single, double, or triple murder, instances of multiple murder can be divided into a number of categories including serial or mass killings. Figure 2 lays out how this report frames the issue of public mass shootings. Starting at the top of Figure 2 , serial murders involve multiple victims killed by the same offender or offenders in separate events over a period of days, months, or years. For this report, m ass murders involve four or more people killed—not including the shooter(s)—in less than one day by the same offender or offenders. Mass murder can then be divided into subcategories—that may or may not involve gunmen—such as massacres perpetrated by people interested in genocide, cult killings, terrorist plots, the slaying of people during the course of drug trafficking, and, as conceptualized in this report, public mass shootings. Among the 78 public mass shootings since 1983 that CRS has identified, 26 occurred at workplaces where the shooter was employed either at the time of the incident or prior to it. The next largest number of public mass shootings occurred at places of education (12). In 2000 in Wakefield, MA, Michael McDermott took three guns to Edgewater Technology Inc., where he was employed, and shot seven coworkers. In 2006, Charles Roberts entered a one-room Amish schoolhouse in Lancaster County, PA, where he shot and killed five students and injured five others. As the above implies, the public mass shootings identified by CRS involve a high level of localization. A mass shooter usually targets individuals in one location or, as the examples below demonstrate, in a small handful of closely clustered geographic sites. In 1988, Michael Hayes shot at people randomly as he roamed his neighborhood in Winston Salem, NC, killing four and injuring five. In 2009, Michael McLendon shot his mother before driving to the nearby town of Samson, GA, where he shot five more people. He then drove to another neighboring town, Geneva, where he shot several more people before killing himself. In total McLendon killed 10 people and injured 6. Many experts agree that a workable, detailed profile of mass shooters does not exist. However, there are some observations that can be made regarding public mass shooters. For instance, among the public mass shooting incidents reviewed by CRS, the gunmen generally acted alone, were usually white and male, and often died during the shooting incident. The average age of the shooters in the incidents identified by CRS was 33.5 years. Only on rare occasions was more than one perpetrator involved in a public mass shooting. CRS has identified three such incidents since 1983. In 1993, Juan Luna and James Degorski killed seven employees at a restaurant in Palatine, IL. In 1998, Andrew Golden and Mitchell Johnson killed 5 people and injured 10 at their middle school in Jonesboro, AR. In 1999 Dylan Klebold and Eric Harris killed 13 and injured 23 at their high school in Littleton, CO, and then killed themselves. Of the public mass shooting incidents identified by CRS for which information on the race of the perpetrator(s) was available, over half of the shooters were reportedly white. The shooters were almost always male. Of the incidents compiled by CRS, only one involved a female assailant. In January 2006, Jennifer Sanmarco shot to death seven individuals—six were fatally wounded in a U.S. postal facility in Goleta, CA, and one death occurred near Sanmarco's condominium, also in Goleta. She killed herself as well. It was common for the gunmen involved in the shootings identified by CRS to kill themselves during their assaults. Forty-one of 81 shooters killed themselves. In 10 instances, law enforcement officers killed the gunmen involved. The shooters identified by CRS ranged in age from 11 to 66 years old. All but 10 were age 20 or older. Most of them were in their 20s, 30s, or 40s (see Figure 3 ). When considering law enforcement's role in coping with public mass shootings, policy makers and the public likely are most aware of how police forces react when they learn of an incident. Public mass shootings typically trigger a rapid police response, followed by an investigation and, potentially, prosecutions and sentencing. Also, while a shooting incident may spur an immediate law enforcement response, the potential for such a scenario impacts law enforcement prevention and preparedness measures. Police are not typically involved in recovery efforts. From a law enforcement perspective, mass shootings tend to be single-jurisdiction issues involving a particular community. As such, while the federal government may not play a direct role in formulating specific state and local practices, it may influence these practices through the availability of grants. For example, the Department of Homeland Security (DHS) offers funding via its Homeland Security Grant Program to "fund a range of preparedness activities, including planning, organization, equipment purchase, training, exercises, and management and administration." Although Department of Justice (DOJ) grants are not necessarily framed in terms of prevention, preparedness, or response, they can certainly address these issues regarding mass shootings. One foundational question is what, if anything, does the federal government want to influence in the states via grant funding related to law enforcement? Should the federal government enhance interagency information sharing and coordination on procedures to evaluate and deal with shooting threats? Should it increase law-enforcement-related grant funding to bolster school resource officer training or the number of metal detectors in academic settings? In this area, the Obama Administration's January 16, 2013, report, Now Is the Time: The President's Plan to Protect Our Children and Our Communities by Reducing Gun Violence ( The President's Plan ), included a commitment to using the Community Oriented Policing Services (COPS) program to incentivize police departments to hire more school resource officers. The plan also indicates that DOJ will develop a model—including best practices—for using school resource officers. Of course, such issues potentially involve a variety of specialists—not only police officials but also public health experts and educators, among others. Grants impacting preparedness may shape first responder training, and grants influencing response could affect the development of law enforcement protocols for responding to mass shootings. Some policy makers may wish to incentivize the establishment and training of tactical emergency medical services (EMS) teams to support law enforcement during instances of mass shootings or related events. These teams could provide medical threat assessments, deliver medical care, and promote law enforcement safety, among other things. Little research has evaluated the effectiveness of such tactical EMS teams in the civilian domain, and policy makers may wish to request additional research in this arena. Congress may debate which elements of law enforcement prevention, preparedness, and response—if any—the federal government could try to influence in the states and localities. In addition to providing financial assistance and incentives for certain law enforcement activities, the federal government may provide assistance in the form of manpower. Policy makers may debate whether federal law enforcement has sufficient authority and resources to assist state and local entities—if requested and if appropriate—in preparing for and responding to mass shootings and related incidents. For example, The President's Plan calls for additional funding for the federal government to train law enforcement, school officials, and others to respond to scenarios involving shooters. While law enforcement's role in crime control traditionally has been viewed as largely reactive , there has been a trend toward enhancing proactive law enforcement efforts. Thus, in the past three decades, much of the policing world has incorporated investigative strategies bent on preventing crimes in addition to solving crimes that have already occurred. However, the effectiveness of proactive law enforcement techniques in preventing public mass shootings is unclear. As modern policing has evolved, several prominent philosophies and techniques—including community policing and intelligence-led policing—have focused on law enforcement preventing rather than solely responding to crime. As laid out by DOJ, "[c]ommunity policing is a philosophy that promotes organizational strategies, which support the systematic use of partnerships and problem-solving techniques, to proactively address the immediate conditions that give rise to public safety issues such as crime, social disorder, and fear of crime." Community policing can employ a range of techniques to control crime, and these techniques can be tailored to the specific needs of individual communities. The federal government has incentivized community policing efforts through DOJ's COPS office. Research on community policing generally speaks to its impact on overall crime rates, and CRS has not identified any comprehensive research on how community policing may be used to specifically address mass shootings. Policy makers may question whether community policing efforts are useful in targeting a specific type of crime (mass shootings) in a specific setting (public places). Based in part on community policing and problem solving efforts, intelligence-led policing initiatives, originally developed in Great Britain, have emerged throughout the nation. After 9/11, intelligence operations were transformed at the federal level as well as at the state and local levels. More and more, intelligence-led policing is not a single methodology, but a framework that encompasses much of modern operational police activity. Similar to community policing, intelligence-led policing relies upon information input (as the basis for intelligence analysis), two-way communications with the public, scientific data analysis (using the basic formula that information plus analysis equals intelligence), and problem solving. The impact of intelligence-led policing cannot yet be fully evaluated because "long term studies of police forces that have fully implemented and adopted intelligence-led policing have yet to be conducted." Further, like research on community policing efforts, available information on intelligence-led policing does not address whether intelligence-led policing may be an effective approach to use in addressing mass shootings. Using intelligence-led policing to thwart mass shooters may be especially challenging for a number of reasons. Mass shooters most often act alone and share few of their plans with others. Typically, they do not engage in ongoing conspiracies that can be infiltrated by undercover police officers or monitored by informants. There may be too few public mass shooting incidents to establish detailed geographic patterns (hot spots) for law enforcement to exploit. Researchers and policy makers have questioned whether law enforcement can develop a profile of a mass shooter to help identify at-risk individuals before a shooting incident occurs. No effective mass shooter profile exists for law enforcement to use to proactively identify potential suspects. One researcher has succinctly noted that "the predictors [for mass murder] are invariably far more common than the event we hope to predict, and mass murder is very rare. Although mass murderers often do exhibit bizarre behavior, most people who exhibit bizarre behavior do not commit mass murder." Aside from usually, but not always, being male, there are few other characteristics found across mass murderers that would be reliable or valid for creating a general profile for individuals most likely to engage in a public mass shooting. This also holds true when examining individuals who carry out mass shootings in specific settings; for instance, "[t]here is no accurate or useful profile of 'the school shooter'." Also of note, criminal profiling is generally utilized after a crime has been committed, and not usually as a preventive tool. In the course of investigating serial crimes by a repeat offender such as a serial murderer, it could be utilized as a proactive tool to narrow the pool of potential offenders before a subsequent crime is committed. However, because mass shooters generally do not have the opportunity to commit a second crime—they are most typically either killed or captured after the mass shooting—investigative analysis would most commonly be employed after the mass shooting to understand how it happened rather than as a tool to identify potential shooters before an incident occurs. All of this does not mean that preventing public mass shootings is wholly beyond the scope of federal law enforcement. For instance, to enhance law enforcement efforts in the violent crime domain, DHS, DOJ, and the FBI have been working to "identify measures that could be taken to reduce the risk of mass casualty shootings." Alternatively, what has come to be known as "threat assessment" may be more appropriately suited to prepare for the threat of potential shooters and to prevent them from harming others. Federal law enforcement has been involved in providing threat assessment approaches to front-line professionals, such as educators, who may encounter potential shooters. Threat assessments are used after a potentially harmful individual has come to the attention of authorities. The assessment process evaluates the threat he or she poses. Certainly, threat assessments may be used to prevent a mass shooting. Law enforcement efforts to train front-line professionals in the assessment process can be seen as an effort geared toward preparing these individuals to cope with threats. The National Threat Assessment Center (NTAC), which is part of the U.S. Secret Service, provides research on threat assessment as well as on targeted violence. The threat assessment approach used by the U.S. Secret Service was developed as part of its broader intelligence activities designed to protect the President and other officials. Nonetheless, it "can be applied with some modification to evaluating risk for other forms of targeted violence." It does not rely on "profiles" of potential malicious actors (as profiles have not proven to be reliable predictors for actual threat), nor does it depend on stated threats as a starting point for evaluating risk (because not every person who makes a threat poses a true risk, and not all persons who pose risks make threats). Within this threat assessment framework, it has been suggested that information be collected relating to (1) facts that bring the subject to the attention of authorities, (2) the subject of interest, (3) attack-related behaviors, (4) possible motives, and (5) potential targets. Of note, law enforcement may not be the only authorities involved in evaluating information and conducting such a threat assessment, but the assessment framework may be one of several tools that law enforcement relies on in an attempt to prevent targeted violence, including mass shootings. Policy makers may wonder whether threat assessment has proved to be a viable tool for law enforcement to use in preventing incidents of mass shootings. Further, they may question if the threat assessment framework could be modified to better serve law enforcement and other professionals who collaborate on efforts to prevent targeted violence. If threat assessments can effectively identify potential mass shooters, policy makers may debate how law enforcement could use this information. One potential option could be to create a criminal watchlist, similar to the Terrorist Screening Database (or terrorist watchlist) to be used in background checks for firearms, among other things. Similar to questions regarding the threshold for placing a suspected individual on the terrorist watchlist, one of the relevant issues would involve establishing criteria for the addition of potential mass shooters to a violent criminal watchlist. There may also be questions about if or how law enforcement may engage with others such as mental health professionals and community leaders in decisions to place someone on such a watchlist. (For a discussion of how the federal government coordinates preparedness efforts for incidents involving mass casualties, see " Preparedness " under the " Public Health Implications " section of this report.) As another means of preparing for mass shootings, some law enforcement agencies have participated in tailored trainings. DHS, for instance, sponsors preparedness courses for shootings as well as webinars, and workshops. The California Highway Patrol has taken advantage of these opportunities and, between August 2012 and January 2013, "has led 18 active shooter trainings on campuses across Northern California." In these two-day classes, officers participate in simulated scenarios; they are trained to respond to a reported incident, bring a shooter under control, and ensure the safety of building occupants. From a law enforcement perspective, public mass shootings are often highly localized incidents involving lone gunmen acting near where they live. Thus, these cases largely do not involve conspiracies or the extensive crossing of jurisdictions. As such, mass shootings generally may be considered a local concern. Nonetheless, federal law enforcement—most notably the FBI—has historically provided assistance, when requested, to state and local law enforcement in the investigation of crimes that do not automatically fall under the jurisdiction of federal law enforcement. Some have expressed concerns that without official authority to respond to such incidents that fall primarily under a single state's jurisdiction, the federal response to these incidents could be slowed by questions of jurisdiction. However, in practice, federal law enforcement has routinely assisted state and local law enforcement in a variety of capacities. The FBI's Office of Law Enforcement Coordination (OLEC), for one, is the liaison between the FBI and the greater law enforcement community. FBI assistance includes a variety of criminal justice information and research, background checks and security clearances, and disaster and hazardous material response teams. Of note, the 112 th Congress passed legislation ( P.L. 112-265 ) that formally authorizes the Attorney General to provide investigative assistance to states in instances of violent crimes in public venues, including attempted and actual mass killings. Some may question whether this authority will change federal law enforcement involvement in responding to and investigating instances of public mass shootings or whether it will simply formalize an already well-established practice. As noted, the definition of a mass shooting is not always consistent across the scholarly, policy, and law enforcement realms. Within the law enforcement realm, a clear definition of mass shootings may be more critical during certain phases of the criminal justice process than others. Take, for instance, the question of who counts as a "victim" of a mass shooting. Is a victim Only someone who was killed at the scene of the crime? Someone who was shot and hospitalized in critical condition for an extended period of time? Someone who was caught in the cross-fire but not critically injured by bullets? Someone who died or was injured in attempting to escape the situation, but who did not die from a gunshot wound? The individual circumstances involving victims are quite varied, but in certain steps of the criminal justice process, the need for a concrete definition may be more pressing. The fact that law enforcement will respond to a public mass shooting may not depend on the ability to pinpoint the exact number of dead or injured victims. However, the details regarding victimization may more greatly impact how the incident is investigated and prosecuted after the conclusion of the mass shooting. Once an investigation begins, information about individuals considered "victims" may be of special interest to investigators and prosecutors. If the shooter survives the incident and is prosecuted, whether or not a victim dies as a result of the mass shooting will influence the charges brought against the shooter. These charges may include actual and attempted homicide, manslaughter, and assault, among others. The charges can, in turn, influence the length of sentence a shooter may receive if convicted of the charges brought against him. A gunman's motives influence how police investigate shootings. A shooter's motives may also drive the charges ultimately brought against him, if he survives the incident. While some cases may be instances of relatively indiscriminate killing, others involve assailants driven by particular hatreds that lead to the targeting of specific groups and can be considered hate crimes and investigated and prosecuted accordingly. Still others can involve ideologically motivated killing, leading to terrorism-related investigations and charges. In considering a shooter's motives and intentions, law enforcement may question whether it is the shooter's resolve to die along with his victims, either in an act of self-inflicted suicide or through "suicide-by-cop," what some have termed "suicide by mass murder." When law enforcement officers respond to a report of a shooter, they are faced with multiple concerns in attempting to disarm and arrest the shooter. Will they have to use lethal force on the suspect? Will the suspect take his own life? Will the suspect try to prolong his life and his rampage through the use of body armor and other defensive tactics? From a public health policy perspective, public mass shootings are mass casualty incidents (MCI) that cause both injury and death. Although public mass shootings are infrequent, the health sector has considerable related experience to bring to bear on preparing for and responding to these events. The health sector addresses mass shootings as it does any other health threat, through (1) prevention, (2) preparedness, (3) response, and (4) recovery over the long term. Prevention focuses on the perpetrators of mass shooting. The other three components of the health sector approach concentrate on the victims of such incidents. Public health options to thwart mass shootings are likely limited. Of these four components, the effectiveness of preventive efforts may be most unclear. Fundamentally, this area likely lacks strong evidence regarding what might successfully stop potential shooters from becoming actual shooters. This evidence could come from evaluation of new or existing policies. Such efforts could help fill a gap in knowledge about what is effective. In terms of preparedness, response, and recovery, proven approaches exist. However, policy makers may wish to consider how existing capacities (or policies to increase capacity) vary across geographic areas and populations. Also, the ability to rapidly evaluate the effectiveness of existing programs and/or deploy resources may hinge on the flexibility of funding structures. Public health interventions are often based on research with large-scale datasets and rigorous information collection regimens. The effectiveness of this approach may be limited largely because public mass shootings are rare, potential perpetrators cannot be identified accurately, and no systematic means of intervening are known to be effective. Regardless, a public health-oriented discussion of prevention of mass shootings should consider the field's traditional approach to stemming any cause of injury or death, highlighting some of the ways that this approach may or may not address public mass shootings. Public health professionals address prevention of injury and death via a three-step process focused on understanding and stemming health-related problems: First, systematic collection of data ( surveillance ) may help define the scope of the problem, identify an outbreak of the problem, and detect trends related to the problem. Second, research may identify characteristics associated with higher rates of injury or death attributed to the problem (called risk factors and protective factors , respectively). Such research may be based on surveillance or other sources of information. Third, efforts to reduce risk factors and enhance protective factors may be developed to stem the problem. These are founded on research pursued in the previous step of this process. Called preventive interventions within the context of public health, such undertakings traditionally focus on victims. However, as mentioned above, in the case of public mass shootings, the focus of prevention is generally on the gunmen involved. Mass shootings are rare, high-profile events, rather than broad trends that require systematic data collection to understand. The public health system does not conduct surveillance specifically for public mass shootings as defined in this report. Some broader information about shootings is collected (e.g., from death certificates) ; however, this information is largely about victims rather than assailants, limiting its usefulness for research into the prevention of mass shootings. For example, the Centers for Disease Control and Prevention's (CDC's) National Violent Death Reporting System (NVDRS) enables participating states to supplement death certificates with information from law enforcement agencies, crime laboratories, coroner or medical examiner reports, health providers, and other state and local agencies. The NVDRS is currently in operation in fewer than half the states. The President's Plan proposes expanding the NVDRS to all 50 states at a cost of $20 million. According to the parameters of this CRS analysis, the victims of public mass shootings are essentially random. Thus, health research into risk and protective factors tied to these incidents would likely focus on things that would either boost or lower the chances that one might become a gunman. One obstacle in identifying such factors is the relatively small data pool available for research (several dozen tragedies over the last thirty years in the United States). Gun violence broadly, rather than public mass shootings, accounts for many more instances of death and injury per year and yields a far larger pot of observable information. This information may be used in research to identify risk and protective factors. Therefore, potential risk and protective factors may have more utility when public health professionals confront the much broader phenomenon of gun violence, not just public mass shootings. Consequently, potential risk factors such as mental illness, substance abuse, exposure to violence, and easy access to guns are all addressed to some extent in The President's Plan, which covers the wider issue of gun violence. The President's Plan also responds to the suggestion by some that health research related to gun violence has been hampered by a statutory prohibition on the use of certain funding to "advocate or promote gun control." The President's Plan states that research into gun violence is not advocacy, and a Presidential Memorandum directs the Health and Human Services (HHS) Secretary to "conduct or sponsor research into the causes of gun violence." Prevention of public mass shootings in a public health context would in theory involve interventions targeted at potential perpetrators, not potential victims. These interventions would be founded on well-tested risk and protective factors, which—as noted above—do not currently exist. If relatively unproven factors were to be used in the development of preventive interventions, this would likely yield many misidentifications. Because the number of public mass shootings in the United States may be too small to offer substantive analysis that could produce effective interventions, it may be most feasible to address gunmen involved in such incidents as a subset of violent offenders. Preventive interventions directed at potential violent offenders may target populations, at-risk subgroups, or high-risk individuals. These approaches may or may not prove effective within the broader context of gun violence, and what effect (if any) they would have on mass shootings is unclear as well. The President's Plan provides examples of each approach: Population-wide interventions include finalizing regulations for mental health parity in private health insurance and ensuring that Medicaid plans are in compliance with parity requirements. Interventions targeting at-risk subgroups include a clarification that doctors are permitted to talk about gun safety with patients who have access to guns and efforts to make mental health and conflict resolution services available specifically for students who have been exposed to violence. Interventions targeting high-risk individuals include a clarification that health professionals are permitted to report to law enforcement violent threats that patients may make. Also, on January 15, 2013, the HHS Office of Civil Rights issued a letter to health care providers to clarify that federal health privacy laws do not prohibit them from disclosing "necessary information about a patient to law enforcement, family members of the patient, or other persons, when [they] believe the patient presents a serious danger to himself or other people." Interventions focused on high-risk individuals can also involve training law enforcement officers to work with mental health professionals to intervene with students in crisis. The federal government has supported coordinated mass casualty incident (MCI) preparedness efforts in large cities since 1997 and in all 50 states, territories, and the District of Columbia since 2002, through federal grants and contracts to public health agencies. These agencies are required to develop plans to integrate responding entities—including federal, state, and local law enforcement; emergency medical services (EMS); private sector health care facilities; and others. These federal grants and contracts support the rapid establishment of interdisciplinary communications (e.g., emergency operations centers) and periodic exercises that bring key responders together to practice before an actual incident, among other things. Although these federal grants and contracts were established in response to concerns about terrorism, they may also help local agencies prepare for MCIs such as public mass shootings. Some are concerned about whether these programs are sufficiently dispersed to enable rural areas to prepare for an MCI. Certain aspects of the health care delivery system, such as the capacity and proximity of critical facilities to a mass shooting, can affect survival from a public mass shooting. Three components of the health care delivery system contribute to MCI readiness: (1) emergency medical services (EMS), (2) hospital-based emergency departments (EDs), and (3) trauma care. Emergency medical services ( EMS ) include 911 call centers, medical care that occurs at the scene of an emergency, the transportation of victims to hospitals, and any treatment that occurs on the way. EMS systems vary by locality—some are operated by municipal or county governments, others by fire departments, and still others by private for-profit companies. This may mean that response times, quality, availability, and preparedness vary by locality. Federal responsibility for EMS is shared across the Department of Transportation, DHS, and HHS, which raises potential concerns about coordination and sustainability. Also, an HHS grant program administered by the Health Resources and Services Administration (HRSA) supports an effort to ensure that emergency medical services are appropriate for children. Hospital-based emergency departments (ED) vary by locality, and not all hospitals have an ED. Rural areas in particular may have both fewer hospitals overall and fewer hospitals that offer emergency care. In both urban and rural areas, some EDs may not function optimally on a day-to-day basis, which would affect their ability to respond to an MCI. EDs may be overcrowded, may "board" patients when inpatient beds are unavailable, and may divert ambulances because they are operating at capacity. The federal government supports EDs through a variety of mechanisms including hospital preparedness grants, interagency coordination, and training of emergency health providers. Through the Medicare and Medicaid programs, the federal government provides payments to hospitals that deliver care to uninsured patients in hospital EDs. These payments (called disproportionate share payments) are an important source of a financial support for EDs. Trauma centers are specialized hospitals with the resources and equipment needed to treat severely injured patients. They provide specialized care that is beyond the capability of the typical ED. Trauma centers are classified into four levels, with lower numbers (I, II) providing more specialized care. Trauma centers may play a role in responding to MCIs, but not all areas have the patient volume to support a trauma center. Distance to the nearest trauma center may be an issue in some MCIs. The federal government provides some funding for trauma centers through grants authorized under HHS, but not of all these programs have received funding. In addition, the CDC is working to raise awareness of trauma centers and has produced research showing the importance of access to trauma care in surviving a severe injury. The medical response to an MCI involves triage and limited treatment of victims on-site, as well as the transfer of victims to appropriate health care facilities for definitive treatment. As described above, federal preparedness funding aims to ensure (1) that the medical components of MCI response work as well as possible when needed, (2) that individual components are as capable as they can be in response, and (3) that medical responders can coordinate and communicate well with each other and with other response sectors such as law enforcement and public education. However, when an incident occurs, local authorities and health systems are largely on their own during the initial phases of a response. The federal government, through HHS (and, when needed, the Department of Defense), can support local efforts to respond to MCIs, making available mobile medical teams, mobile field hospitals, medical supply and pharmaceutical caches, and medical evacuation and transport. In general, however, mass shootings resolve quickly, often before federal operational assistance can be delivered. In the event of a public mass shooting or other MCI, as with any emergency medical situation, delaying treatment while determining a patient's insurance status or ability to pay for health care services may prove fatal. The Emergency Medical Treatment and Active Labor Act (EMTALA) protects against such a delay. EMTALA requires a hospital that receives Medicare payments (as the vast majority of hospitals do) to screen a patient for emergency medical conditions without regard for the patient's ability to pay. If the screening identifies an emergency medical condition, EMTALA requires the hospital to stabilize the patient. In instances where a patient's injuries are too severe to be treated at an ED, a patient may be sent to a trauma center. EMS or local EDs may determine whether a transfer to a trauma center is needed. Trauma centers are also subject to EMTALA (if the hospitals receive Medicare payments) and are required to accept transfers when an ED has determined that the trauma center possesses the specialized services that the patient needs but the ED lacks. Recovery of affected individuals and communities over the long term may require ongoing services to meet the physical and mental health care needs of both victims and responders. Ongoing services may involve inpatient and outpatient medical care; psychosocial interventions such as pastoral or peer counseling; and population-level interventions such as public announcements about common reactions to traumatic events (which can help normalize people's experiences and reduce anxiety around symptoms that are likely to be transient) or information about how to discuss an incident with children. The availability of such services in a timely and accessible manner may also be important for reducing long-term consequences such as posttraumatic stress disorder. Although federal resources generally focus on the immediate aftermath of an MCI, the federal government may fund public health interventions as well as programs that support the physician and behavioral health workforce and other infrastructure. The federal government also has a role in providing and financing health services that victims and responders may access. For an individual's long-term recovery from a public mass shooting, lack of insurance or inability to pay for health care services may limit the treatment options available (e.g., physical rehabilitation or counseling). Thus, financial support may play a key role in long-term recovery. Schools are unique institutions. They have a mission of great importance to our nation—they are responsible for keeping our children safe while educating them and helping prepare them to be responsible and productive citizens. All levels of government are involved to some extent in this mission. As mentioned earlier in this report, 12 of the 78 public mass shootings identified by CRS occurred in academic settings. Eight of these happened at primary or secondary education facilities. One incident, the December 14, 2012, shooting deaths of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, CT, has heightened congressional interest in school security. Policy makers are examining whether school security can be further enhanced, and if so, how best to accomplish that goal. Four of the 12 public mass shootings in education settings involved high school or middle school students as assailants. The federal government has supported efforts to preempt students from engaging in gun violence at school. More broadly, it has promoted policies to curb violence in schools, such as anti-bullying programs, which may or may not stem public mass shootings by student perpetrators. This section of the report focuses on those federal programs and initiatives administered by the Department of Education that may be relevant in the event of a public mass shooting in a school setting. The President's Plan was released following the Newtown tragedy—it includes several provisions specifically related to schools. However, funding for these provisions may not be sufficient to provide meaningful assistance to all schools that could potentially benefit. Difficult decisions confront policy makers. They must consider how to make the greatest possible improvements in student safety while likely being faced with limited federal resources to devote to safety initiatives. Policy makers may have to decide whether funds should be spread across many activities so that each activity gets some additional funding, or whether funding should be concentrated in fewer programs believed to be most cost effective. This decision is made even more difficult because research on effectiveness is limited for many school security programs. This may lead to consideration of whether more funding should be provided for research into program effectiveness, and if so, whether it would restrict funding for existing school security programs. Policy makers must also consider the importance of continuity of funds for local program success. It can be difficult for local school districts to plan, develop, and implement programs if they cannot be certain of a reliable funding stream. In recent years much of the dedicated funding for school safety programs provided by the Department of Education has been cut. Some programs were cut because they were perceived as too small to make a difference. Others were cut because they failed to demonstrate their effectiveness. For example, funding for the Safe and Drug Free Schools and Communities Act (SDFSCA) program, the federal government's primary program aimed at preventing drug abuse and violence in and around public schools, has declined from $435 million in FY2009 to $65 million in FY2012. Department of Education guidance has divided the crisis management process for schools into four phases. Those four phases, in sequential order, are prevention, preparedness, response, and recovery. Because emergency planning at institutions of higher education occurs in a significantly different environment and context, this report focuses on emergency planning at the elementary and secondary school level. Prevention (and mitigation) involves broadly structured efforts to help schools reduce the need to respond to crises including mass shootings. This stage of crisis management is critical for educators. If students do not feel safe at school, they will not be able to focus their energy on the most important task before them—learning. According to the Department of Education, this first stage of crisis management should include the following activities: connecting with community responders to identify potential hazards, reviewing the most recent school safety audit, determining who is responsible for overseeing violence prevention at the school, soliciting staff input on the crisis plan, reviewing school incident data, determining major crime and violence problems at the school and assessing how effectively they are currently being addressed, and conducting an assessment to determine how existing threats may impact the school's vulnerability to particular crises. Improving school climate is one strategy for mitigating and preventing a variety of crises, including mass shootings (if the perpetrators involved in these incidents are students). A CDC report states that a positive school climate is "characterized by caring and supportive interpersonal relationships; opportunities to participate in school activities and decision-making; and shared positive norms, goals, and values." Research has indicated that one of the most important elements in a positive school climate is for students to have a feeling of school connectedness. School connectedness is defined as "the belief by students that adults and peers in the school care about their learning as well as about them as individuals." The Department of Education's Office of Special Education Programs funds a Technical Assistance Center on Positive Behavioral Interventions and Supports. The Center provides capacity-building information and technical assistance to schools, districts, and states who are implementing a school climate protocol called School-wide Positive Behavioral Interventions and Supports (SWPBIS). SWPBIS is a three-tiered prevention-based approach to improving school-wide disciplinary practices. According to the Center, SWPBIS is used in more than 9,000 schools across 40 states. SWPBIS has been linked to reductions in student suspensions and office discipline referrals. Bullying prevention is also an important aspect of improving school climate. The federal government recognizes the importance of this issue and has become increasingly involved in bullying prevention initiatives in recent years. Research indicates that both victims of bullying and those who engage in bullying behavior can experience both short and long-term effects resulting in psychological difficulties and social relationship problems. A GAO literature review of seven meta-analyses on the impact of bullying on victims found that bullying could result in psychological, physical, academic, and behavioral issues. In addition, a Secret Service study on school safety and school attacks found that "Many attackers felt bullied, persecuted or injured by others prior to the attack." The SDFSCA defines school resource officers as career law enforcement officers assigned by a local law enforcement agency to work with schools and community based organizations to: (A) educate students in crime and illegal drug use prevention and safety; (B) develop or expand community justice initiatives for students; and (C) train students in conflict resolution, restorative justice, and crime and illegal drug use awareness. The President' s Plan would provide an incentive for DOJ's Community Oriented Policing Services (COPS) grants to be used to hire more school resource officers in the current year, and would seek $150 million in funding for a new Comprehensive Safety Grants program. This new grant program would provide school districts and law enforcement agencies with funding to hire new school resource officers and school psychologists. This new funding stream could also be used to purchase school safety equipment, develop or expand school safety proposals, and to train crisis intervention teams of law enforcement officers to respond and assist students in a crisis. School resource officers are popular with the public. A recent Pew research study found that 64% of those surveyed supported having armed security guards or police in more schools. However, some researchers and civil rights organizations have expressed concern about increasing the presence of school resource officers in schools, arguing that the presence of law enforcement can have a negative impact on the learning environment, and may lead to more school suspensions and referrals to the juvenile justice system. On December 12, 2012, the Senate Judiciary Subcommittee on the Constitution, Civil Rights and Human Rights, held a hearing titled "Ending the School-to-Prison Pipeline." In his opening statement Chairman Richard Durbin stated that: For many young people, our schools are increasingly a gateway to the criminal justice system. This phenomenon is a consequence of a culture of zero tolerance that is widespread in our schools and is depriving many children of their fundamental right to an education. Preparedness involves marshaling the necessary resources to ensure that they are available in the event of a crisis, including shooting incidents. This involves confirming that the school's current emergency plan is consistent with the National Incident Management System; acquiring the necessary equipment and first aid resources to address a potential crisis; establishing procedures to account for the location of all students; developing procedures to communicate with staff, families, and the media; ensuring all school staff are familiar with the school's layout, safety features, utility shutoffs, etc.; and conducting practice drills for students and staff. One of the proposals included in The President's Plan would provide $30 million in one-time grants to school districts to help them develop and implement Emergency Management plans. In addition, a current SDFSCA program—Readiness and Emergency Management for schools (REMS) provides competitive grants to LEAs to strengthen and improve their emergency response and crisis plans. No grants were awarded in FY2012. The Department of Education has developed resources and training materials that are available online to help schools develop emergency plans and respond to crises. However, these resources are not limited to addressing a school shooting crisis; they are intended to be applicable to a range of potential crises that could impact a school (e.g., natural disaster, pandemics, terrorism). Indicators of School Crime and Safety data show that many schools have been increasing measures intended to improve school safety. In school year 1999-2000, 54.1% of surveyed students (ages 12-18) reported that their school had security guards and/or assigned police officers; this percentage had increased to 68.1% by school year 2009-2010. Other school security measures that have increased between school year 1999-2000 and school year 2009-2010 include the use of security cameras (from 19.4% to 61.1%); locking or monitoring doors (from 74.6% to 91.7%); and requiring faculty and staff to wear badges or IDs (from 25.4% to 62.9%). The President's Plan would set up an interagency group to release a model set of emergency management plans for schools, houses of worship, and institutions of higher education. It would also require the Department of Education to collect and disseminate best practices for addressing school discipline. Maintaining crisis response capacity is required of schools by 92% of states. Press accounts of school shootings have provided anecdotal evidence indicating that school emergency planning (lock-down procedures and practice drills, etc.) may have minimized deaths and injuries in incidents of mass shootings. However, federal legislation does not regulate the content or quality of these plans, and the comprehensiveness and implementation of these plans vary considerably across school districts. An organized and coordinated response to a crisis is based in large part on the prevention and preparedness activities that schools have adopted and implemented. According to the Department of Education, during a crisis (which can include mass shootings), schools should undertake the following activities: identifying the type of crisis that is occurring, activating the incident management system, identifying the appropriate response to the crisis (e.g., evacuation, shelter in place, lockdown, etc.), implementing the plans and procedures established in the preparation phase, ensuring that important information is being communicated to staff, students and parents, and ensuring that emergency first aid is being provided to the injured. Many school shootings last only minutes—as a consequence, teachers and school staff become the immediate responders out of necessity in many crises, sometimes heroically sacrificing their own lives to protect the children in their care. Community first responders, including law enforcement and emergency medical personnel, are also key to ending a crisis as quickly as possible. Among their many tasks, they must immediately subdue the shooter, if he is still alive; and they most coordinate all the emergency services that are required by survivors of the shooting. Recovery efforts are focused on returning students to the learning environment as soon as possible. These efforts include restoring school facilities, identifying the supports and services needed by students, staff, and families to help them recover from the crisis, connecting individuals to services, including mental health and counseling services, and allowing sufficient time for recovery and deciding how to commemorate the event. The primary Department of Education program available to schools to assist recovery efforts following a crisis is Project SERV (School Emergency Response to Violence). This program provides education-related services to schools that have been disrupted by a violent or traumatic crisis. Local educational agencies and institutions of higher education (IHEs) are eligible to apply for these grants. Project SERV funds may be used for a wide variety of activities, including mental health assessments, referrals, and services for victims and witnesses of violence; enhanced school security; technical assistance in developing a response to the crisis; and training for teachers and staff in implementing the response. School counselors can also play an important role in facilitating a school community's recovery following a crisis. School counselors can provide an avenue for students to be heard by a caring adult, and can provide needed services or make referrals for services to community providers. The President's Plan includes several provisions that would increase student access to mental health services. It seeks $150 million in funding for a new Comprehensive Safety Grants program. One of the authorized uses of this program would be to hire school counselors. In addition, the proposal seeks $50 million to train 5,000 additional mental health professionals to serve youth in schools and communities, and $25 million to provide mental health services for trauma, conflict resolution, and other school-based violence prevention strategies. The proposal would also provide $55 million for a new Project AWARE which would train teachers and other adults to recognize and help youth with mental illness and work with a variety of community agencies and organizations to ensure youth who need help are connected to service providers. When addressing public mass shootings, many of the policymaking challenges may boil down to two interrelated concerns: (1) a need to determine the effectiveness of existing programs—particularly preventive efforts—and (2) figuring out where to disburse limited resources. The law enforcement and public health fields have lengthy histories of applying preventive approaches to their work. However, the utility of widely employed preventive measures in these areas to fight public mass shootings is far from clear. For example, it appears that intelligence-led policing fails to address this threat. Likewise, preventive public health approaches reliant on research drawn from large data sets, covering broad populations, and examining general trends may not adequately address relatively rare—though devastating—public mass shootings. Given this, policy makers may be interested in supporting the development of useful preventive schemes in the law enforcement and public health arenas. In the area of education, preventive efforts may be more effective. Fostering a positive school climate can be seen as a key element in preventing shootings. Additionally, the use of school resource officers as a preventive measure is popular among Americans. Yet, there are those who question the impact of such officers on the learning environment. Policy makers confront the task of disbursing resources among a wide assortment of programs to tackle public mass shootings. Which efforts are more important than others? For example, should prevention trump response in most cases? Should programs that have multiple uses be favored over others that may be seen as more focused (or vice versa)? For example, which should receive more support related to dealing with mass shootings: EMS or efforts to cultivate positive school climate? Which untested programs or approaches should be evaluated thoroughly? Who should evaluate them? How long should funding exist to tackle the threat of mass shootings? All of this hints at an overarching difficulty confronting experts interested in crafting policy to address mass shootings. Essentially, baseline metrics gauging the effectiveness of policies to thwart public mass shootings are often unclear or unavailable. This lack of clarity starts with identifying the number of shootings, themselves, since no broadly agreed-to definition exists. Several questions flow from this issue. How many people have such incidents victimized? How much does prevention of, preparedness for, and response to such incidents cost the federal government? What measurements can be used to determine the effectiveness of such efforts? In other words, and most importantly, how will we measure our successes or determine our failures in fighting this problem?

Summary: This report focuses on mass shootings and selected implications they have for federal policy in the areas of public health and safety. While such crimes most directly impact particular citizens in very specific communities, addressing these violent episodes involves officials at all levels of government and professionals from numerous disciplines. Defining Public Mass Shooting Policy makers may confront numerous questions about shootings such as the December 2012 incident at Sandy Hook Elementary School in Newtown, CT, that claimed 27 lives (not including the shooter). Foremost, what are the parameters of this threat? How should it be defined? There is no broadly agreed-to, specific conceptualization of this issue, so this report uses its own definition for public mass shootings. These are incidents occurring in relatively public places, involving four or more deaths—not including the shooter(s)—and gunmen who select victims somewhat indiscriminately. The violence in these cases is not a means to an end—the gunmen do not pursue criminal profit or kill in the name of terrorist ideologies, for example. One Measure of the Death Toll Exacted by Public Mass Shootings. Applying this understanding of the issue, the Congressional Research Service (CRS) has identified 78 public mass shootings that have occurred in the United States since 1983. This suggests the scale of this threat and is intended as a thorough review of the phenomenon but should not be characterized as exhaustive or definitive. According to CRS estimates, over the last three decades public mass shootings have claimed 547 lives and led to an additional 472 injured victims. Significantly, while tragic and shocking, public mass shootings account for few of the murders or non-negligent homicides related to firearms that occur annually in the United States. Policymaking Challenges in Public Health and Safety Aside from trying to develop a sense of this phenomenon's scope, policy makers may face other challenges when addressing this topic. To help describe some of the health and safety issues public mass shootings pose, this report discusses selected policy in three areas: law enforcement, public health, and education. While mass shootings may occur in a number of settings, the education realm is one that has received particular attention from policy makers, officials, and the public alike—at least since the 1999 shooting at Columbine High School in Littleton, CO. The tragedy at Sandy Hook Elementary has renewed such concerns for many. In the areas of law enforcement, public health, and education, this report discusses some key efforts to prevent mass shootings as well as efforts geared toward preparedness and response. Policy measures that deal with recovery are also discussed within the context of education and public health initiatives. Policy Effectiveness and Outlay of Resources. Many of the policymaking challenges regarding public mass shootings boil down to two interrelated matters: (1) a need to determine the effectiveness of existing programs and (2) figuring out where to disburse limited resources. Finally, baseline metrics related to this problem are often unclear or unavailable. This lack of clarity starts with identifying the number of shootings themselves, since no broadly agreed-to definition exists. Several questions flow from this issue. How many people have such incidents victimized? How much does prevention of, preparedness for, and response to such incidents cost the federal government? What measurements can be used to determine the effectiveness of such programs? This report does not discuss gun control policies and does not systematically address the broader issue of gun violence, which can include topics such as gun-related suicide and a wide variety of gun-related crimes. Also, it is not intended as an exhaustive review of federal programs addressing the issue of mass shootings.