EFTA00104960.pdf

A02:8 INCIDENT REPORT .N:S J.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Part I - Incident Report 1. Institution: Incident Report Numbs • MCC New York ••;s a , c25 2. Inmates Name: 3. Register Number: 4. Date of Incident: Epstein . Jeffery 76318-054 07/2312019 1:27am 6. Place ofinadont: 7. Assignment: 8. unit: SHU Miler Cell 124 Unassigned ZA 9. Incident: Self-Mutilation . 10. Prohibited Ad Code (s): 228 11. Description of Incident (Dale: 07/23/2019 Time: 1:27AM Staff became aware of incident): On July 23.2019 al approx. 127am Whale working in the Special Housing Unit Myself and S/0 =heard noise coning from the M tier cell 124.Upon arrival UM's Epstoin.Jelfery/t76318-054 cell mate ((UM Tartagrionea78514.054)was at the door stating UM Epstein.Jeffery/t76318-054 had attempted to hang himself. I kept a visual Mule S/0 Mgrabbed the door keys and called for assistance. After Secunng I/M Tartaghone#78514-054 and removing him from the colt, entered then placed UM Epstein on his side and removed a orange homemade rope from his neek.UM was tirealhng at this time But unresponsive. Addition staff and Ops It arrived UM was then removed from SHU 12. Typed NamoiSil mg Employee: i 13. Dale And-Time: 07/23/2019 3:30am . Incident Report ye Inmate by 15. Dale In ent Report Dekvered. 6. Time Inodent Repot Delivered: (Type Name/Sic Part It - Committee Action 17. Comments of Inmate to Committee Regarding Above Incident: 1--1 18. A. It is the finding of the committee that you: Committed the Prohibited Act as charged: Did not Commit a Prohibited Act Committed Prohibited Act Code (s). B. In The Committee is referring the Charges) to the OHO for further C. at a l The Committee advised the inmate of its fmdirry and of the right to Be an appeal within 20 calendar days. 19. Committee Decision is Based on Specific Evidence es Follows: 20. Committee action and/or recommendation if referred to DHO (Contingent upon DHO finding inmate committed prohibited act): 21. Date and Time of Action: (The UDC Chairman=s signature certifies who sal on the UDC and that the completed report accurately reflects the UDC proceedings). Chairman (TypedName/Signature): ember (Typed Name): Member (Typed Name): INS I RUC IONS: All deals outside of heavy rule are for staff use only. Begin entries with voided by staff. the number 1 and work up. Entnes not completed will be Distribute: Onginal.Cenual File Record. COPY-1-DHO: COPY-2-Inmate after UDC Acton: COPY 3-Inmate within 24 hours of Part I Preparation PDF Prescribed by P5270 Replaces BP-A0288 of AUG 11 EFTA00104960  22. Date And Time Investigation Began Part III - Investigation 23. Inmate Advised Of Right To Remain Silent: You are advised of your right to remain silent at all stages of the discipline process. Your silence may be used to draw an adverse inference against you at any stage of the discipline process. Your silence alone may not be used to support a finding that you have committed a prohibited act. The Inmate Was Advised Of The Above Right By At (Date/time) 24. Inmate statement and attitude 25. Other facts about the incident, statements of those persons present at scene, disposition of evidence, etc. 26. Investigator's comments and conclusions 27. Action taken Date and Time Investigation Completed Printed Name/Signature Of Investigator Title POF Prescribed by P5270 Replaces BP-5288.052 Of MAY 94 EFTA00104961