A02S8
N.17




INCIDENT REPORT


# Part I – Incident Report

1. Institution: MCC New York
   Incident Report Number: 3382555

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

3. Place of Incident: SHU Tier Cell 124
   Assignment: Unassigned
   Unit: ZA

4. Incident Self-Mustation
   Prohibited Act Code(s): 228

10. Prohibited Act Code(s):
   Time: 1:27AM
   Staff became aware of incident:

On July 23,2019 at approx. 1:27 am While working in the Special Housing Unit myself and SIO award noise coming from the Miller cell 124 Upon arrival /IM's Epstein Jeffery#76318-054 cell mate /IM/Tartaglione#76514-054 was at the door stating /IM Epstein Jeffery#76318-054 had attempted to hang himself. I kept a visual while SIO grabbed the door keys and called for assistance. After Securing /IM Tartaglione#76514-054 and removing him from the cell, entered then placed IM Epstein on his side and removed a orange homemade rope from his neck /IM was breathing at this time But unresponsive. Addition staff and Ops LL arrived /IM was then removed from SHU.

12. Typed Name/Signing Employee:
   Date And Time: 07/23/2019 3:30am

14. Incident Report (Type Name/Sign)
   Inmate By:
   Date Incident Report Delivered:
   Time Incident Report Delivered:

## Part II – Committee Action

17. Comments of Incident 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 Reason.
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).

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

**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



Prescribed by P5270

PDF

Replaces BP-A0288 of AUG 11

EFTA00104960

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

EFTA00104961