EFTA00105170



A0298
N.47




INCIDENT REPORT


Part I – Incident Report

1. Institution: MCC New York
2. Inmate's Name: Epstein, Jeffery
3. Place of Incident: SHU M-Tier Cell 124
4. Incident: Self-Mutilation
5. Incident Report Number: 3282555
6. Register Number: 76318-054
7. Assignment: Unassigned
8. Unit: ZA
9. 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. 1:27am While working in the Special Housing Unit Myself and S/O heard noise coming from the M-tier cell 124 Upon arrival I/M Epstein, Jeffrey#76318-054 collate (I/M Tartaglione#78514-054) was at the door staling I/M Epstein, Jeffrey#76318-054 had attempted to harm himself. I kept in visual while S/O grabbed the door keys and called for assistance. After Securing I/M Tartaglione#78514-054 and removing him from the cell enforced then placed I/M Epstein on his sole and removed a coupe homemade rope from his neck I/M was breathing at this time.

But unresponsive. Addition staff and Ops LT arrived I/M was then removed from SHU

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

14. Incident Report (Type Name/Signing Employee By)
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 Heard.
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=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

EFTA00105171

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 ___