———, -— -_ A0258 INCIDENT REPORT NA? J.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS art | — Incident Report 1 Tistitution: MCC New York SHU M-Tier Cell 124 8 Incident: Seif. Mutilation 11. Description of incident (Date: 97/23/2019 Time: 1:27AM Staff became aware of incident): heard noise comin, from the M Ser com = anived Uhl wos then remove? tom SFU 17. Comments of inmate to Committee Regarding Above Incident: [7]. The Committee is referring the Charge(s) to the DHO for further The Committee advised the inmate of its finding and of the fight an appeal within 20 calendar days. 18. A. Itis the finding of the committee that you: lei FE Sereteemne ena sore Did not Commit a Prohibited Act. Committed Prohibited Act Code (s). oS nr EE ee ES Sa et Sr 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 (The UDC Chairman=s signature certifies who sat on the UDC and that the completed report accurately reflects the Ube De proceedings) ————— airman nature). Member (Typed Name): mber ( lame): | : All items oul javy tule are for use only. in enines number Work up. ies ni | voided by staff. Fai re 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 EFTA00105445