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Page 273 fi i, nea en. A0258 INCIDENT REPORT NT J.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS Part | - Incident Report _ 7. Institution: MCC New York incident Report aia sD R DAS. 2. Inmate's Name: 3. Register Number: 4. Date of Incident: ime: Epstein , Jeffery 76318-054 07/23/2019 1:27am 6. Place of Incident: 7. Assignment: 8. Unit: SHU M-Tier Cell 124 Unassigned ZA 9. Incident: Self-Mutilation / 10. Prohibited Act Code (s): 228 byG} (br NC) ng Employee: . Date And Time: _ . 07/23/2019 3:30am - Inadent Repo e Inmate By 15. Date Incident Report Delivered: 6. Time Incident Report Delivered: | (Type Name/Sigres: Part Il — 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 Hear, Cc. The Committee advised the inmate of its finding and of the right t to file an appeal within 20 calendar days. iy 19, Committee Decision is Based on Specific Evidence as Follows: bY H 20. Committee action and/or recommendation if referred to DHO (Contingent upon DHO finding inmate committed prohibited act): li 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): : ; : All items outside of heavy rule are for stall use only. egin entries with the number 7 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 | Preparation PDF Prescribed by P5270 Replaces BP-A0288 of AUG 11 DOJ-OGR-00024812