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Page 1122 BP-A0292 APR 16 U.S. DEPARTMENT OF JUSTICE (Institution Inmate Name: EPSTEIN, JEFFREY EDWARD Reg. No. 76318-054 bu6} (oN) (DIF YC} Team/caseworker: ONASSIGNED ADMISSION Regular Unit: SURI MGR ; i eels, Cell: a Violation Date Time PENDING CLASSIFICATION : or Reason: Rec'd: 2019-07-10 _ Rec'd: 15:26 Admittance Date Time Authorized: Rel.: Rel.: Pertinent Information: in Separation Information: Li Special Housing Unit Cell Number: Pee Inmate Is In: DS: Ap AD Status Is Inmate on Medication: Medical Department Notified: Out of cell time Medical Date Shift 5 a 5 SH | Exercise —s Staff Sign OIC Signature (Total min/hrs) —— = 07-21-2019| Morn ¥ by); (bCMC) Kb(G); (DFC) 07-21-2019) Day be 07-21-2019) Eve | Y 07-22-2019 Morn | ¥ 07-22-2019 | Day Y Y | No 01:00 07-22-2019 Eve ij Morn Day Eve Morn Day Eve Morn Day Eve Morn Day Eve Morn Day Eve EXPLANATORYNOTES:Pertinent Info: i.e., Epileptic; Diabetic; Suicidal; Assaultive; etc. Meals/SH: Shower - Yes (Y); No (N); Refused (R)Out-of-Cell Time: (LL) Law Library,(LV) Legal Visit, (U) Unit Team, (P) Psychology, (E) Education, (H) Haircut, (C) Chapel, (R) Recreation, (X) Property Issue, (V) Visit, (M) Medical, (C) Court, (O) Other — Yes (Y) if applicable / Enter Actual Time Period Start and End (i.e., 0930 — 1030 hrs) in Out of Cell Time Block. Medical: Medical providers will sign the segregation log each shift and the record sheet each time the inmate is seen by a medical provider. At a minimum, the record sheet must be signed at least once each day by the medical provider. Comments: i.e., Conduct, Attitude, etc. Additional comments on reverse side must include date, signature, and title. OIC Signature: OIC must sign all record sheets each shift. (OIC - Unit Officer) PDF Prescribed by P5270 This form replaces BP-292(52) dated AUG 2011. DOJ-OGR-00025344