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Page 816 Form 583 Report of Incident Incident #: NYM-19- Submitted By: 0076 Date/Time Of Incident: 7/23/2019 1:27 AM Section 1: General Information Staff Aware Date: 7/23/2019 1:27 AM FBI Notified: No USMS Notified: No Indicate Where Incident Occurred: Main Facility Location Level 1: SHU “]AssaultOn inmate C] Assault On Staff C0 Assault, Attempted On Inmate LJ Assault, Attempted On Staff (C Disruptive Behavior (] Escape From Non-secure Facility (J Escape From Secure Facility (] Escape, Attempted From Non-secure Facility (] Escape, Attempted From Secure Facility C Fight (CJ Inmate Death (J Institution Disturbance (CD Introduction Of Contraband LC) Lethal Weapons Discharge C] Self Mutilation CJ Setting A Fire (-] Sexual Act, Non-consensual On Inmate (C0 Sexual Assault On Staff -] Sexual Contact, Abusive On Inmate (CJ Sexual Harassment, Repetitive C) Staff Homicide (] Strike, Food C2 Strike, Work Suicide Attempt (] Use Of Force (] Use Of Force/Applications Of Restraints C Use of Restraints, Pregnant/Postpartum Method: Hanging/Asphyxiation Level 2: Housing Unit, Special (SHU) Level 3: 9 SOUTH SHU Institution Locked Down: No Modified Operations: No Cause Of Incident Known? No Cause Of Incident (] Alcohol (0 Commissary OD Debts (J Disrespect Issue (J Drugs CO Ethnic Conflict (_] Food Issue C Geographical Conftict (1 Interfering with Staff duties C] Property Issue J Racial Conftict () Recreation Equipment C Religious Issue (J Security Threat Group Conflict () Sexual Pressure (1) Sporting Events (CD Telephone (J Theft C Visiting (_-] Work Issue UNCLASSIFIED/LIMITED OFFICIAL USE ONLY/LAW ENFORCEMENT SENSITIVE This document is marked Unclassified/Limited Official Use Only/Law Enforcement Sensitive and may be disseminated, with proper attribution, to active Law Enforcement, DOD, or U.S. Intelligence Agencies. This document, or any segment/attachment thereof, may not be released without the approval of the Bureau of Prisons to any media sources, any non-law enforcement entity, the general public or those without a “need to know.” It contains information that may be exempt from public release under the provisions of the Privacy Act (5 U.S.C. 552). 1 of 3 DOJ-OGR- 00025134