A0298
.N.47




INCIDENT REPORT


# Part I – Incident Report

1. Institution: MCC New York
   Incident Report Number: 3282555

2. Inmate's Name: Epstein, Jeffery
   Register Number: 76318-054
   Date of Incident: 07/23/2019
   Time: 1:27am

3. Place of Incident: SHU M-Tier Cell 124
   Assignment: Unassigned

4. Unit: ZA

5. Incident: Self-Mutilation
   Prohibited Act Code(s): 228

11. Description of Incident (Date: 07/23/2019 Time: 1:27AM Staff became aware of incident):

On July 23, 2019 at approx. 1:24 am While working in the Special Housing Unit Myself and S/O Silva heard noise coming from the M tier cell 124 Upon arrival JIM's Epstein, Jeffery #76318-054 can mate JIM Entailment#76318-054 at the door station JIM Epstein Jeffery #76318-054 had attempted to hang himself. I kept a visual while S/O Silva grabbed the door keys and called for assistance. After Securing JIM antiglare #76318-054 and removing him from the cell entered then placed JIM Epstein on his side and removed a orange homemade rope from his neck JIM was breaking at this time.

But unresponsive. Addition staff and Ops LI Anderson arrived JIM was then removed from SHU.

12. Typed Name/Signature of Reporting Employee: Masullo,J
   Date And Time: 07/23/2019 3:30am

14. Incident Report Delivered to Above Inmate By (Type Name/Signature):
   Date Incident Report Delivered: 15

Part II – Committee Action

17. Comments of Inmate to Committee Regarding Above Incident:

18. A. It is the finding of the committee that you:
   - Commit the Prohibited Act as charged:
   - Did not Commit a Prohibited Act.
   - Commit the Prohibited Act code(s):

B. The Committee is referring the Charge(s) to the DHO for further Heard On.
   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/or recommendation if referred to DHO (Contingent upon DHO finding inmate committed prohibited act):

21. Date and Time of Action:
   (The UDC Chalman is signature certifies who sat on the UDC and that the completed report accurately reflects the UDC proceedings).

Chairman (Typed Name/Signature): Member (Typed Name): Member (Typed Name):



PDF

Prescribed by P5270

Replaces BP-A0288 of AUG 11



EFTA00040960


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 ___

PDF

Prescribed by P5270

Replaces BP-S288.052 Of MAY 94

EFTA00040961