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kc;:-; INCIDENT REPORT J.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS 1 institution: MCC New York 2. Inmate's Name. Epstein Jeffery 8. Place of Incident SHU Cell 124 9' Inadelt Self-Mutilation . Part I — Incident Roped 3. Register Number 76318-054 7. Assignment Unassigned 10 4. Date of Incident 7/23/2019 Indent Report Numbe 8. Un ZA 1:27am 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 klasulb.J rang Employee: 13. Date And Time 14. incident Report to Above Inmate By (Type Name/Sig ). 15. Datelhoc ent Report Delivered: 07/23/2019 3:30am 16. Time Incident Report Delivered Part II - Committee Action 17. Comments of Inmate to Committee Regarding Above Incident: 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. r7 The Committee is referring the Charge(s) to the OHO (or further g,ariaan The Committee advised the Inmate of its finding and of the right to file an appeal within 20 calendar days. 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 1 and work up. Entnes not completed will be voided by staff. 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 Part III - Investigation 22. Date And Time Investigation Began 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