EFTA00061677 | | :--- | :--- INCIDENT REPORT U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

Part I- Incident Report
1. Institution: MCC NEW YORK			Incident Report Number:
2. Inmate's Name:	3. Register Number:		4. Date of Incident:08/09/2019		5. Time:1:40PM
6. Place of Incident:SPECIAL HOUSING UNIT VISITING ROOM	7. Assignment:UNASSIGNED			8. Unit:7 NORTH
9. Incident:ATTEMPT INTRODUCTION DRUGS		10. Prohibited Act Code(s):111A

11. Description of Incident (Date: 08/09/2019 Time: 1:40PM Staff became aware of incident): On August 9,2019 at approximately 1:40PM I S/O/S while assigned as the Special Housing Unit Officer I proceeded to enter the 9 South visiting room. As I walked towards the door I observed through the visiting room door inmate attempt to grab a unknown item from his visitor. Once inmate reached to grab the item I called the door and called for a lieutenant. Once I was able to enter the visiting room, I gave inmate a direct order to walk of the visiting room, to conduct a visual search. Inmate complied and a visual search was conducted. Operations lieutenant was contacted and inmate was removed from the unit.

12. Typed Name/Signature of Reporting Employee:R.C		13. Date And Time:08/09/2019 6:00pm
14. Incident Report Delivered to Above Inmate By(Type Name/Signature):	15. Date Incident Report Delivered:		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. The Committee is referring the Charge(s) to the DHO for further Heaven.C. 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 Chairman=s signature certifies who sat on the UDC and that the completed report accurately reflects the UDC proceedings). INSTRUCTIONS: All items outside of heavy rule are for staff use only. Begin entries with the number 1 and work up. Entries not completed will be voided by staff. Distribute: Original-Central File Record; COPY-1-DHO: COPY-2-Inmate after UDC Action; COPY 3-Inmate within 24 hours of Part I Preparation PDF Prescribed by P5270 Replaces BP-A0288 of AUG 11 EFTA00061678 | 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. Inmate statement and attitude: 25. Other facts about the incident, statements of those persons present at scene, disposition of evidence, etc. 26. Investigators comments and conclusions: 27. Action taken: Date and Time Investigation Completed: ___ Printed Name/Signature of Investigator: ___ Title: ___ PDF Prescribed by P5270 Replaces BP-A0288 of AUG 11 EFTA00061679