Form 583 Report of Incident Incident 8: NYM-19- Submitted By: 0082 DateITIme Of Incident: 8/10/2019 6:33 AM Section 1: General Information Staff Aware Date: 8/10/2019 6:33 AM FBI Notified: Yes USMS Notified: Yes Indicate Whore Incident Occurred: Location Level 1: SHU Level 2: Housing Unit, Special (SHU) VAL3fIrteldoift:L_ O Assault On Inmate O Assault On Staff O Assault, Attempted On Inmate O Assault, Attempted On Staff O Disruptive Behavior O Escape From Non-secure Facility O Escape From Secure Facility El Escape, Attempted From Non-secure Facility O Escape, Attempted From Secure Facility O Fight El Inmate Death O Institution Disturbance O Introduction Of Contraband O Lethal Weapons Discharge O Self Mutilation O Setting A Fire O Sexual Act. Non-consensual On Inmate K Sexual Assault On Staff O Sexual Contact, Abusive On Inmate O Sexual Harassment, Repetitive O Staff Homicide K Strike, Food K Strike, Work a Suicide Attempt O Use Of Force O Use Of Force/Applications Of Restraints O Use of Restraints, Pregnant/Postpartum Method: Hanging/Asphyxiation Main Facility Level 3: 9 SOUTH SHU Institution Locked Down: Yes Modified Operations: No Cause Of Incident Known? No Catise Of Incident K Alcohol O Commissary O Debts O Disrespect Issue K Drugs O Ethnic Conflict • Food Issue K Geographical Conflict O Interfering with Staff duties El Property Issue O Racial Conflict O Recreation Equipment K Religious Issue O Security Threat Group Conflict O Sexual Pressure El Sporting Events O Telephone heft O T K Visiting ci Work Issue Section 2: Inmates Involved UNCLASSIFIED/LIMITED OFFICIAL USE ONLY/LAW ENFORCEMENT SENSITIVE This document Is marked Unclassified/Limited Official Use Onty/Law Enforcement Sensitive and may be disseminated. with roper attribution, to active Law Enforcement, DOD, or U.S. Intelligence Agencies. This document, or any segment/attachment the pot may not be released without the approval of the Bur