EFTA00040960.pdf

kc;:-; INCIDENT REPORT J.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Part I — Incident Roped 1 institution: 10 MCC New York Indent Report Numbe 2. Inmate's Name. 3. Register Number 4. Date of Incident Epstein Jeffery 76318-054 7/23/2019 1:27am 8. Place of Incident 7. Assignment 8. Un SHU Cell 124 Unassigned ZA 9' Inadelt Self-Mutilation . 10. Prohibited Act Code (s): 228 11. Description of Ineklent (Date: 07/23/2019 Time: 1:27AM Staff became aware of incident): On July 23.2019 at approx. 1:27am While working in the Special Housing Unit Myself and S/0 Silva beard noise coming from the M tier cell 124.Upon arrival UM's Epstein.Je(ferya76318.054 cal mate (IN Tartagllone//78514.054)was at the door stating UM Epsten.Jeflerya76318.054 had attempted to hang himself. I kept a visual while S/0 Silva grabbed the door keys and called or assistance. A rSecuring artag ione 4 and removing him from the coll.i entered then placed WM Epstein on his side and removed a orange homemade rope from his neck.UM was breathing at this time But unresponsive. Addition stall and Ops Lt Anderson arrived WM was then removed from SHU 12. typed NamelM rang Employee: 13. Date And Time klasulb.J 07/23/2019 3:30am 14. incident Report to Above Inmate By 15. Datelhoc ent Report Delivered: 16. Time Incident Report Delivered (Type Name/Sig ). Part II - Committee Action 17. Comments of Inmate to Committee Regarding Above Incident: 18. A. It Is the finding of the committee that you: B. r7 The Committee is referring the Charge(s) to the OHO (or further g,ariaan Committed the Prohibited Act as charged: The Committee advised the Inmate of its finding and of the right Did not Commit a Prohibited Act. to file an appeal within 20 calendar days. Committed Prohibited Act Code (s). 19. Committee Decision is Based on Specific Evidence as Follows: 20. Committee action and/Of recommendation if referred to (OHO (Contingent upon DHO finding inmate committed prohibited act): 21. Date and Time of Action: (The UDC Chairman-s signature certifies who sat on the UDC and that the completed report acasrately reflects the UDC proceedings). Chairman (typed Name/Signature): Member (Typed Name): Member ( typed Name): INSI RUCTIONS. Ail items outside of heavy rule are for staff use only. Begin entries with the number and voided by staff. 1 work up. Entnes not completed will be Distribute: Original-Central File Record: COPY-1-DHO: COPY-21nmate after UDC Action; COPY 3-Inmate within 24 hours of Part I Preparation PDF Proscribed by P5270 Replaces BP-A0288 of AUG 11 EFTA00040960  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. Innate 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 PDF Prescribed by P5270 Replaces BP-6288.052 Or MAY 94 EFTA00040961