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JjL*fytibOw\ ^jySk iMMu CEwV^feL W mfe^L Texas Department of Criminal Justice OFFICE USE ONLY Grievance #: <STFP 1 OFFENDER Date Received:.

O 1 SLr 1 GRIEVANCE FORM Date Due: k Grievance Code: . o ip^mme: Offender-Name v^ i^Xh TDCJ #_dbmM2\ Investigator ID #: Unit housing Assignment: Extension Date: Unit where incident occurred: Date Retd to Offender:

You must try to resolve your problem with a staff member before you submit a formal complaint. The only exception is when appealing the results of a disciplinary hearing.

Who did you talk to (name, title)? ^T[<rr£Zfo frj)V%ftW When?

What was their response? VJD^\uOC What action was taken? Jb0G State yourr grievance in the space provided. Please state who, what, when, where and the disciplina

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Appendix F OFFICE USE ONLY Texas Department of Criminal Justice Grievance #: UGI Reed Date: STEP 2 OFFENDER HQ Reed Date:.

GRIEVANCE FORM Date Due: Offender Name:. TDCJ#JMM. Grievance Code:.

Unit: %MftJDV\^V Housing Assignment: C-~ \ 'b —?J~> -"f? Investigator DD#:.

Unit where incident occurred: KlfvLlX Un> yr Extension Date: _

You must attach the completed Step 1 Grievance that has been signed by the Warden for your Step 2 appeal to be accepted. You may not appeal to Step 2 witha Step 1 that has been returnedunprocessed.

Give reason for appeal (Be Specific). / am dissatisfiedwith the response at Step 1 because...

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1-128 Front (Revised 11-2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM (OVER) Appendix G Wfemlfo iPAifefei »w ,%#*****;*», Rawest*****5 . . 02-.APR 2015 -PW SI: ^'""^— jFiflST La' ' 1 i HCUSU. •3^\^omk1 S"Vc5 \WrO K) jTJL 77D0 V CHRISTOPHER A. PRINE CLERK. ..;#». *:'••%.• ? i'00220&&93 fli|.|-|ll>il*j».||i|j'l>j|f|ll(l'J||l|J|jllf|||'|'I"|||l|i>lli'l ,j£ Offender Signature : VO Date: Crtfo^flUS Grievance Response:

Signature Authority: Returned because: *Resubmit this form when corrections are made. OFFICE USE ONLY Initial Submission CGO Initials:.

LJ 1. Grievable time period has expired. DateUGIRecd: LJ 2. Illegible/Incomprehensible.* Date CGO Reed: (check one) Screened Improperly Submitted LJ 3. Originals not submitted. * Comments: LJ 4. Inappropriate/Excessive attachments.* Date Returned to Offender LJ 5. Malicious use of vulgar, indecent, or physically threatening language. 2"1 Submission CGO Initials: DateUGIRecd: LJ 6. Inappropriate.* Date CGO Reed: (checkone) Screened Improperly Submitted Comments: CGO Staff Signature: Date Returned to Offender: 3d1 Submission CGO Initials: DateUGIRecd: Date CGO Reed: (checkone) Screened Improperly Submitted Comments: Date Returned to Offender:

1-128 Back (Revised 11-2010) Appendix G 8fo frM B AvW? kg ft Action Requested to resolve your Complaint, ^n^^rtp^'o ^YxV^rto Offender Signature: YO-MXK ggjnjg^ Grievance Response:

Signature Authority: , Date: If you are dissatisfied with the Step 1 response,you may submit a Step 2 (1-128) to the Unit GrievanceInvestigator within 15 days from the date of the Step 1 response.

State the reason for appeal on the Step 2 Form. ———^————n-nmw——~ '• a—— —^— ~~^——^—i ^ ^—f^—— ^gsa=ganHHHHHHHHHzHHHHHHHHBBaeaBsjBgs=^= Returned because: *Resubmit this form when the corrections are made. [~11. Grievable time period has expired.

I~l 2. Submission in excess of 1 every7 days. * OFFICE USE ONLY Initial Submission UGI Initials: Q 3. Originals not submitted. * Grievance #: .

I 14. Inappropriate/Excessive attachments, * Screening Criteria Used: _ |~1 5. No documented attemptat informal resolution. * Date Reed from Offender: n 6. No requested reliefis stated. * Date Returned to Offender: n 7. Malicious use of vulgar, indecent, or physically threatening language. * l^SHbjnissifia UGI Initials:.

T~l 8. The issue presented is not grievable. Grievance #: . - f~l 9. Redundant, Referto grievance # Screening Criteria Used: l~l 10. Illegible/Incomprehensible. * Date Reed from Offender: C] 11. Inappropriate. * Date Returned to Offender: UGI Printed Name/Signature: - S^ubmission UGI Initials:.

Grievance #: Application of the screening criteria for this grievance is not expected to adversely Screening Criteria Used: Affect the offender's health.

Date Reed from Offender: _ Medical Signature Authority: Date Returned to Offender:

1-127 Back (Revised 11-2010) Appendix F