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Page 3315 Form 583 Report of incident incident #: NYM-19- 00 Submitted By: N’ Diaye, L. Date/Time Of Incident: 8/10/2019 6:33 en Section 1: General Information ee Fr Staff Aware Date: 8/10/2019 6:33 AM FBI Notified: Yes USMS Notified: Yes Location Level 1: SHU ype Of oO Assault On Inmate CJ Assault On Staff CC Assault, Attempted On Inmate CE Assault, Attempted On Staff CD Disruptive Behavior [] Escape From Non-secure Facility (C Escape From Secure Facillty (1) Escape, Attempted From Non-secure Facility CU Escape, Attempted From Secure Facility (1 Fight C Inmate Death CJ Institution Disturbance . C] introduction Of Contraband [] Lethal Weapons Discharge CO Self Mutilation (J Setting A Fire (J Sexual Act, Non-consensual On Inmate (1 Sexual Assault On Staff | Sexual Contact, Abusive On Inmate CO Sexual Harassment, Repetitive CO Staff Homicide C Strike, Food CU Strike, Work Suicide Attempt C) Use Of Force [1] Use Of Force/Applications Of Restraints CJ Use of Restraints, Pregnant/Postpartum Section 2: Inmates Involved Level 2: Housing Unit, Speci Method: Hanging/Asphyxlation indicate Where Incident Occurred: Main Facility al(SHU) Level 3: 9 SOUTH SHU Institution Locked Down: Yes Modifled Operations: No Cause Of Incident Known? No 4 Cauisé Of Incident: 2.8 [] Alcohol CJ Commissary (CJ Debts CJ Disrespact Issue OO Drugs C1 Ethnic Conffict CJ Food Issue (J Geographical Conflict C] interfering with Staff duties CL) Property Issue C1 Racial Conftict CI Recreation Equipment C1 Religious Issue CJ Security Threat Group Conflict (_] Sexual Pressure C Sporting Events CJ Telephone C] Theft CJ Visiting CL Work Issue Ee OO eeSeSeSFSFSFSsashee 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 attribution, to active Law Enforcement, DOD, or U.S. not be released withoul the approval of tha Bureau o public or those without 2 “need to know.” It contains Privacy Act (5 U.S.C, 552}. proper of, may neral af the Intelligence Agencies. This document, or any segment/attachment the { Prisons to any media sources, any non-law enfercement entity, the g information thal may be exampt from public release under the provisions 1 of 3 DOJ-OGR- 00026904