.e-" l , _ E a copy of the order of appointment is 'appended.

W,@U' 15 No.` '

IN THE_ sUPREME_ CoURT oF TH`E UNITED_ sTATEs

]h @\.EJQ J\\~»Jr Q§\;: 1 maj l?q\/ 51'<{6 _PETiTioNER @@Uvoeocr~M/u areas (You`r Name) _ l . mens lay @m§ ‘ -v`s. - ' ,- - . - - » ' - '- _ Auel/él@@sta,©lea< ~~ 642 imc of fixed ,_-REsPoNDENT<s) ` Couf+ clc Cf\-_~\\r\c¢\ jqpp€q/ 5 n MOTION FOR LEAVE TO PROCEED IN FORMA PAUPE'RIS The petitioner asks leave to file the attached petition for a writ of certiorari without prepayment of costs and to proceed iu forma pauperis Please check the appropriate boxes:v E’T’etitioner has previously been granted leave t0 proceed iu forma pauperis in the following court(s): Cou\f+ oil Cr.Mu\c¢L/)_M&lf @1[ 721`45'.(/(5 b\`ii. G_>uf'f /VoH/\en\ Dir Oa/)azb,‘\/ €i'I’l' Clrcun+ Co\~lf‘+ c>`lc AUA€Q/F E Petitioner has not previously been granted leave to proceed m forma pauperis in any other court. 'Zi)etitioner’s affidavit or declaration in support of this motion is attached hereto. ‘ \:l Petitioner’s affidavit or declaration is not.atta-ched because the court below ` appointed counsel in the current proceeding, and: l:l The appointment was made under the following provision of laW: " ` , or

: Signature) AFFlDAVlT OR DECLARAT|ON lN SUPPORT OF MOT|ON FOR LEAVE TO PROCEED IN FORMA PAUPERIS I, Mi>wlaf paul ja{€j , am the petitioner in the above-entitled case. In support of . / . . my motlon to proceed m forma pauperzs, I state that because of my poverty I am unable to pay the costs of this case or to give security therefor; and I believe I am entitled to redress.

1. For both you and your spouse estimate the average amount of money received from each of the following sources during the past 12 months. Adjust any amount that was received Weekly, biweekly, quarterly, semiannually, or annually to show the monthly rate. Use gross amounts, that is, amounts before any deductions for taxes or otherwise.

lncome source Average monthly amount during Amount expected the past 12 months next month You ` Spouse You Spouse Emp|oyment $ 0 $ $ 0 $_ Se|f-emp|oyment $ 6 $ $ 0 $ lncome from real property $ o $ $ 0 $ (such as rental income) » interest end dividends $ 0 $ $ 0 $ cifie $ 0 $ $ 0 $ A|imony $ @ $ $ G $ child support $ 0 $ $ 0 $ Retirement (such as social $ 0 $ $ 0 $ security, pensions, annuities, insurance) Dieebiiiiy (suen es social $ 0 $ $ 6 $ security, insurance payments) Unemp|oyment payments $ C) $ $ Q’ $ Pub|ic-assistance $ O $ $ '© $ (such as welfare) Other (specify): $ C) $ $ 0 $ Total monthly income: $ 6 $ $ © $

_ ,.e/ 2. List your employment history for the past two years, most recent first. (Gross monthly pay is before taxes or other deductions.)

Emp|oyer Address Dates of ' . Gross monthly pay Emp|oyment . 'KD. CJ. ~fll Texas Pn‘zw\ ‘i,/z//eb‘ ~ ? $ C’> `_ $ $

3. List your spouse’s' employment history for the past two years, most recent employer first. (Gross monthly pay is before taxes or other deductions.)

Emp|oyer Address Dates of Gross monthly pay Emp|oyment $ $ $

4. How much cash do you and your spouse have? $ Below, state any money you or your spouse have in bank accounts or in any other financial institution.

Financia| institution Type of account Amount you have Amount your spouse has

D% o $ 0 . $ 63 $ $ $ $

5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings |:\ Home E Other real estate Value Value |:l Motor Vehicle #1 l:l l\/Iotor Vehicle #2 Year, make & model - Year, make & model Value Value |:l Other assets Description

Value

6. State every person, business, or organization owing you or your spouse money, and the amount owed.

Person owing you or Amount owed to you Amount owed to your spouse your spouse money '_M_ $___O___ $_L__ $_______ $ $h_ $ 7. State the persons who rely on you or your spouse for support.

Name Re|ationship v Age /i//i /i//l' _ /l//¢

8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, or ~ annually to show the monthly rate.

You Your spouse Rent or home-mortgage payment (include lot rented for mobile home) $ 0 $ ghi Are real estate taxes included? E Yes U No Is property insurance included? I:l Yes l:] No Utilities (electricity, heating fuel, water, sewer, and telephone) $ 0 $_/VA__ Home maintenance (repairs and upkeep) $ 6 $_M` Feed _ ~ ' $__O_ $_/Wi__ Clothing y $ 0 $_A/A_' Laundry and dry-cleaning $__O__ $M_ Medical and dental expenses $ L%F $ g /(}

You Your spouse Transportation (not including motor vehicle payments) $ 9 $ Recreation, entertainment, newspapers, magazines, etc. $ 0 $ Insurance (not deducted from wages or included in mortgage payments)

Homeowner’s or renter’s $ O $ Life $ 9 $ Health $ d $ Motor Vehicle $ 0 $ other; u.IiMi 6 Meeé'cel €e'.oai/.< $ 2 ”L‘l $ . . , hew Taxes (not deducted from wages or included in mortgage payments) (specify): - $ 0 $ Installment payments

Motor Vehicle $ 0 $ Credit card(s) $ 0 $ Department store(s) v $ O $ other: null ven/ics _ $ 3m 1 $ l l Ar€:\f" Alimony, maintenance, and support paid to others $ $

Regular expenses for operation of business, profession, or farm (attach detailed statement) $ $ other (epeeify): geee+ /i//l _ $ $ Total monthly expenses: Are\f’€f l//é 3 5

C¢_> “H» C° 7+6 i`»\»

9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months?

E Yes MNO , lf yes, describe on an attached sheet.

10. Have you paid - or will you be paying - an attorney any money for services in connection with this case, including the completion of this form? E Yes § No If yes, how much?

If yes, state the attorney’s name, address, and telephone number: 11. Have you paid_or will you be paying_anyone other than an attorney (such as a paralegal or ` a typist) any money for services in connection with this case, including the completion of this form? l:l Yes w No If yes, how much?

If yes, state the person’s name, address, and telephone number: 12. Provide any other information that will help explain why you cannot pay the costs of this case, fw¢fi`jei/t+/ qu\¢li'<oi,dp€c{ »& c/e'\`i€c/ FiFil/. B/quili`i¢{ buie fe /'/icc¢r<i`mh'or\/ xe;j`;:,/,`:/y n 0 l I declare under penalty of perjury that the foregoing is true and correct.

Executed on: ' , 20 (Signature) No.

|N THE SUPREME COURT OF THE UN|TED STATES

711¢>¢\/105 /€qv 5i'c(@5 _PETiTioNER (Your{\lame) VS. 511de inc fean _REsPoNDENT(s> Cou(`+ of C¢`\'Ml'f\"il A/,d€¢/j ON PET|T|ON FOR A WR|T OF CERT|ORAR| TO C<>U\F+ o'l(' C(i`f\*\ i r\Cil Af/€Cil$ ol[ fCXQj (NAME OF COURT THAT LAST RULED ON MER|TS OF YOUR CASE) PET|T|ON FOR WR|T OF CERT|ORAR| 7711»»1¢15 law §i‘</ef ~#¢/3}3/82» (Your Name§ 166‘/ f:r"l. ’2_05*( (Address) %’i’irle§)’ee Co{s’\'>//,Zz/(Q{- 75886 (City, State, Zip Code)

(Phone Number) QuEsTioN(s),PREsENTED _ ` `/{f M¢ ffa+e C¢dr+¢ illegal q<+i'ov\ ,`,\ v,‘@(q+,'e¢\ ah +/ie -bi.$._ Co»§f%fh,i+/on ‘crea“re.r. art /'m{)¢:z/i'rvi'€r\i/' - -}_o a pe~h'+i'<>v\ef prece€c/i`nj fe Fe¢/é(ql Ceqr+. qv\¢/~ '[i’|i'¥lj hid/def @p/i'CQ`/~l(o¢\ per Lc){;+ Oi[ yqbéqf drqu l Fd'r;uqi\+` h 413 bl,§. CS_ 4'254,' ami +lim due 'J,'/iij<,v\¢€ Me pe+i+/`ovier iad been -ua¢acceisfq\ ~ id jeff/43 fha NN/_;|j 5%¢1+€ Coul‘+ fe Cc»rrecf fh€ QN`O(` wbi¢lt'fg z Cqu$£ o“FMe_ ,`M/e¢/,`a,en~f' y an '~I]ie pui")-;ov\ef§ lmine year )'M'l’»i'+€, e'/ /i'Mi'h+' ..'|`¢v\f bej-i`v\ ‘/~v rout, wl¢}\ pe(Ml{j_/"or\ (rm~\'-Me Fa¢[€l‘ql -. -' _Ceur`+§_/-¢i~l lie/zia lie.`a//oi;ueJ ¢c_» pile /h>i'r qo,Q/i<a#/?)'\ - l-feri~wrl‘r`of iebeez` cerpus,T/idj rederi/3 ,H-,ehr` ("i`j}\`*;f° blue pf°¢eFF-/ oc,qj€'av\ %/ie/€'N~}i'on<r§ owe year jl~q+u+e of /i'mi'~+a+i'on_f 'éi@ waived i,oi`+}\ d fi\owi¢j o'i/'. JL(@_ cli')l"?€n{€/ q jhsvo/`nj'f'liai~ f/ie o`fFGAAikj ~ 51‘4`}€ Q:Mfr re{ut§c?d ~/'o carr enf fha errot, canal q jhewln {i\¢¢i< ‘/'}ie:erro¢~' l`z q Canz~h'iuh'oml i/t'oiq+`lor\, a/)ou)i ' peii'+-'vv\€r‘j jo proceed fe Fe¢ierc¢\ Covif`l' md pile hi`$/h€t` app li.('q+i'oii\ 'Fof l\/t)£i\' rle ha heed Coquj. mud K§zfo$i“\¢) *h€i`/` ' Y‘(jl\+ `/'o due proc€%. `p.le“/e 7‘4'<€ no*'€ #“¢* 714 C”w\$#i'fuh'o\flql arcor l i`¢\ u€>'h">"\- i`s Juri`$¢{i`€+lonq§\ »i`¢\ nature/ami ' l Cleo\rl\‘ herec/ i’n the receij<l.

LlST OF PART|ES Dd All parties appear in the caption of the case on the cover page. [ ] All parties do not appear'in the caption of the case on the cover page. A list of all parties to the proceeding in the court whose judgment is the subject of this petition is as follows: pe+i'+ i' ee<zi`!

7/£§\!\445 Kq\/ 51`({€5 Wj/?/BZ» m.‘el\ael an.'+ 1554 /'TiM. 2054 fenne§zee Cele»iy /H.

75886 ge§po ndan+'." -11ie F+Q~i/e e‘F /excij Ci>v\ri' cna C(i'mi'r\a( /f//den/j P.o. tim IUOS CQ{)\`+¢¢| `J¢e+.'e.~.

Auz+i'r\ / fean , 7/i

TABLE OF CONTENTS oPiNioNs BEi_oW ...................... j ....................................... .......................... 1 JuRisDicTioN ................................................................................................................... z coNsTiTuTioNAi_ AND sTATuToRY PRovisioNs iN\/oLvED ............................... 336 sTATEi\/iENT oF THE cAsE l//-ie REA_soNs i=oR cRANTiNG THE wRiT ......................................................................... ,i /.//L coNcLusi`oN...........................'..‘ ..... k .................................................................................. I3 iNDEx To APPENDicEs APPENDi)<A Li;r ei‘ cezes W{ adm dire mied ep¢>- r/~QM.

APPENDix B APPENijiX c APPENDix D ' APPENDix_E APPEND|X F

n TABLE OF AUTHOR|T|ES»C|TED ; CASES PAGE NUIV|BER Haiie/ V>'. Li.5.; 33<l F¢J- ae;cef+.'emri Den.'e¢l ', _ A 5.€+.421,;')8<) d.z.qzii,' /z t.L=d.~z¢{/eo`<i ` 3 Ari/W v. A/Ie.~ ,’ L/5z F,e¢/. /zzli (¢ees) ,3`,/_4__` FQMes i/. <ei»\ ; 66 fed 1371 (s+h.c.‘r. /<i<)$) FA_- B/("{ev\f V é u.AK~»\o~w\ fee/1 NQ!U.`)' Lle Mij, 3$%/' q( ji(i'- l<]?q; d L¢# L_£d, 14 é/<( _"_U\. /\/.Jl./i.ci?\ v. ciiyv er lsle 7¥- 1416 /',1)¢/~ 133 (z+h CU' ‘1°"°) 3 STATUTES AND RULES “ ', ‘28 u.§.c.§zz“i¢( (¢/)(/)(b) fz»ci_ c.\¢ii proc lea ¢~ , _3__. up ii\ ii F<J. 'C\`i/i\ pr¢>C. » /7~ (L) /'5) lt ~ - ~j'- ~- * Ul§. C.A. Cov\j+. /qvv\€,\¢l '§ § 2` g ?_,.Zj€-_ 1€;)' l,{\jic\. § ’1£?'_(2'?5. 'F’lq‘i.-_ i,i.§, 61 Am. Coeif ./lM£ML 5'$/‘/ , ,`§`_' OTHER 72an Co</€ alc C(i'Miriq| lam ce </e(re; //.o 7 eli <q) ";&/ ` u`%*b)€ of Aq+f\Oil`H'l'Cj C.'fed,‘ Con`h"“d€€/ Coije)' Leeis ii. amy ; ne dd. yiizjz»is?*/;/ié 5.¢¢. wig _ L.L`J.a_d. 504 (|¢,q/,) Egjl\ v. F/ee¢jde¢d,;‘i\¢.,' lime Ai.bi /Aé,' 593 ,ii..,»_ed. 911 indem Aeveiepw»'<¢\+ ; sea stead m ' fee A/fo y ;50»1_ u~§`. lo?$}iil’L` 5.€+. 470 see /4/¢0 1 ' Gé.’” Canf.'l/ . jwfhwd‘lf'¢r“ ` l l ' en of i‘<w+ze (iwé) )"5 F'LJ~ 555 , 5‘{3 )’.o)~zal 871 .~n`+elieii v. me»j~er', 145 d.s.-U‘//-zli‘i; 55 5.¢+. /i,-L,/M; 7‘1 l.Ec/. 338 lde a /¢/‘4'\" ber- \13 "zA" .1 314 ,. `3A" MM"; _\ ?'7-4. |N THE SUPREME COURT OF THE UN|TED STATES PET|TION FOR WR|T OF CERTIORAR| Petitioner respectfully prays that a writ of certiorari issue to review the judgment below.

40PlNlONS BELOW [` ] For cases from federal courts: The opinion of the United States court of appeals appears at Appendix to the petition and 1s

[ ] reported at ' ; OI`, [ ] has been designated for publication but 1s not yet reported; or, [ ] is unpublished to

The opinion of the United States district court appears at Appendix the petition and 1s [ ] reported at ; or, [ ] has been designated for publication but 1s not yet reported; or, [ ] is unpublished d m For cases from state courts; 7’¢1.{,'3 en+ fexao OFF¢./Le(er` , /l/o Co{),e; +.i Se/\ Ple¢\ze §eice/ 1'~> Appendix The opinion of the highest state court to review the merits appears at Appendix _A_ to the petition and 1s [ ] reported at ; or, [ ] has been designated for publication but is not yet reported; or, [ ] is unpublished

The opinion of the f€Xa§ Couf+ of C(i M\Nil AD/]€q/ 5 COuI-t appears at Appendix A_` to the petition and ls [ ] reported at ; Or,

[ ] has been designated for publication but is not yet reported; or, |;)Q is unpublished

JUR|SD|CT|ON [ ] For cases from federal courts: The date on which the United States Court of Appeals decided my case ' was

[ ] No petition for rehearing was timely filed in my case. [ ] A timely petition for rehearing was denied by the United States Court of s Appeals on the following date: , and a copy of the order denying rehearing appears at Appendix

[ ] An extension of time to file the petition for a writ of certiorari was granted to and including (date) on (date) in Application No. _A

The jurisdiction of this Court is invoked under 28 U. S. C. §1254(1). [)Q For cases from state courts: LQH Cour+ AC*"°"\ v`v\ CC~r{ The date on which the highest state court decided my case was M.

A copy of that decision appears at Appendix . K/<> Cc»pq fe Se¢i¢{,

[ ] A timely petition for rehearing was thereafter denied on the following date: , and a copy of the order denying rehearing

appears at Appendix

[ ] An extension of time»to file the petition for a writ of certiorari was granted to and including _`_ (date) on *` (date) in Application No. _A '

The jurisdiction of this Court is invoked under 28 U. S. C. §1257(a).

CONST|TUT|ONAL AND STATUTORY PROV|S|ONS lNVOLVED u/lm{ qc+i`c.¢\ faKQ-'\ wlrl\owl jur,`s¢li`<}i'ov\ i's \/vi`cl',' xi` /V.A.A»C.lo. V. C\`f¢{ of /( I€,T){./° 525 F.'g¢l, 133 (S+l\ C.\,_ 10)0) F€c/' ~l(~ilei el'] Ci‘v. lamp /z (b) (z) u‘z‘C-A- Cev\ié. AH. "5.§' 2_ ` "Jqdi`ei`e\ fumes are nor subd‘e¢f fe waver:' )P lewis v. Ceze/ ; 5ie u.é. ‘3»i3, giiq F’i}' iii, 5.<+.1i7i/-, i.ie¢i.ed. etc (i<i<ii») Fed. i?d\es et Ccv. lgrv¢. /oz,z v/lll Citi`~¢cv\§ have 4 (ijl+ fe due prb<e% 41 App¢a/."@,,nqpl\radc</) ,v( u.z.c./l. cwi. AM,i¢l. 5’ +/‘i.

“A q(pli'c¢iflov\ #F,>,r w(i+ of l\_ebe¢i$ G>rpi:i‘) )£."l~ecl 511 q pctfw\ /'/t cw+c>cl~., éubjec+ /~o 614+€ Cour`+ Ji'cly€w\m+,i`! ¢/oie fe be tolled wi+l\'\¢\ one year, i`¢\ par-13 -Fn>wi J-he, /ai~eff a{/ (A) flie dale en which ~H\e fulgem€r\+ bemme ici/nol by conclu$i'oh of Ji`f'ec+ rec/lew or +/ie axp€fa>‘i'¢>w of fha )"i'i¢\¢ £>.r zee/<i` sack ('€Vi`€u.>/' (l§) 1112 Jq*¢ on whi`¢,ll\ 1416 ‘:fwip€/l'w\€*\f“fo lll‘nj an eppllce+i'on crea+e</ by sign fin V,'olq#i'ov\ oi( flieConzf/+u+,'ovi m laws el +he united 4+¢1+65 /`; rer»:eved, r`¢ applic¢'\+ cud§' (N&Y€'\+€’¢{ prima plli`r\j by jack Ac'h'oi\. as is oi.$.<.s § 11¢|1{ (d)(/] "\,‘L/f (a) {]€+i+iev\er nies pr€iier\+<el Fre¢\~ flllvij his habedi Ce¢pwi‘ pe+‘i*i`c~'\ as q redul} of “i'//equ F+Me acf/w",¢/ia li'Mi'+q+i'i>v\S loaded will m>1~ begin jo run until r/ie_ van impediment r'§ revl’\°V€C£-" j er _ A.e,l\er vt A//M ,‘ 451 /Te¢, /zzr (w<>i) jewel v. <e.',\; ge /je¢/. /371<5+h.;'.'r./d<¢5) 51L¢¢cl< etc Iq'f»‘$<(i'€`f{‘or\ g\/ef Q Cu$€ `rev\(lef`$ q iac{?cm¢n+ \/Oi`d' qwcl l"l’ Mai/ qlu.wi~/$ be C¢lla+€rqlly q'l/ack€c{:l et Hdnes V. u.§. ; 334 K’b¢/, ~eo,' Cer¢i'e¢ari benie¢l_j %5' s.c+. qeé; esa u.a'. qz"i /z L.EJ.»LJ. seq `13..

Co»\$‘l`\"}`v\'l’;ci\a\‘ OM.cl Sfa`l'u,+w~l \Oiro\/i'$(vsi.§ /`A\/o‘uec/"’.~C'e.t`f ` 7’/.ere ,‘5 ne fire<_L.'/ni+ lof Q#aC/<.‘».j a V,,;d judje,`“m,_" >F , Ejjl vi F/€@¢*a“¢\/¢l, i-“<-'j me /i/.b. ibb,' 533 ,i/.ei-zd- viz u.;.c.A. A(+_ 111 g 11 1a U-$-C~/l § /zqi~/z<r§ _“ ;Wc'i\/L`l“l cf Jmfi`d¢ll`¢'l`\'v"\ of Svile`€cl~ MQ#QI el( $\A:+ will -Q¢ce$+ q cai.u< a'l~ qvi»~/ H4je of fha laracee¢/vi:?f, aacl /'+ i`5 ino+ subjec)¢ fo iam/erc x( ' ' Madéro bev€lbpmen+; 303 5‘*\"`10[ 39'6; 5€€ /4/5° ` j 501 1,1.$./0'?3 )//z_ 5.<}. q7o/' jeeel/e , ,///%/’/'/ U~§.C\fl. /‘lr}. Ji(§' `Z'» u.i.<._A. § i»)_¢ii »/245

l '/

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CONCLUS|ON The petition for a Writ of certiorari Should be granted.

Respectfully submitted, %,w¢i¢ Date:

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|N THE SUPREME COURT OF THE UN|TED STATES

jlww\az K’m/ Fl‘c{ei - _ PETlTloNER (Your |\iame) vs. 1/»¢ jude of ivan _ RESPoNDENT(S)

Coqr+ pf C.'¢`rm’v\ql /4|9/¢4[/ PROOF OF SERV|CE I, 711° M“§ /2“;/ 5“'({€! , do swear or declare that on this date, , 20 , as required by Supreme Court Rule 29 l have served the enclosed MOTION FOR LEAVE TO PROCEED IN FORMA PAUPERIS and PETITION FOR A WRIT OF CERTIORARI on each party to the above proceeding or that party’s counsel, and on every other person required to be served, by depositing an envelope containing the above documents in the United States mail properly addressed to each of them and With first-class postage prepaid, or by delivery to a third-party commercial carrier for delivery Within 3 calendar days.

The names and addresses of those served are as folloWs: Cour+ §§ C(`e‘f‘~\iv\o¢\ A'»O.p€"l/f of 72’%45 `/4#/1/;6/€//( W.o,o€¢,y` /130@ Q.-.,p,'+al Fm+,'o~v\ jumll,,??m. 73 7// I declare under penalty of perjury that the foregoing is true and correct.

EXecuted on , 20 fha g (Signature)

i*.l¢ JBA4904 /EU39/HS05 TEXAS DEPARTMENT OF CRIMINAL JUSTICE 115:07:00 HEALTH SUMMARY FOR CLASSIFICATION 08/07/2014 NAME: SIDES,THOMAS RAY DOB: 08/24/1967 P U L H E'S TDCJ#: 01313182 SID#: 03739765 WGT: 158 LBS -------<r-- UNIT: E HOUSING: B-4'l-18B HGT: 6'01" 3 3 3 1 l l JOB: UNASGN MEDICAL C C C A A A P P P H

I; FACILITY ASSIGNMENT (CHECK ONE) A. NO RESTRICTION B. BARRIER-FREE FACILITY C. SINGLE LEVEL FACILITY D. SUITABLE FOR TRUSTEE CAMP? X YES__NO II. HOUSING ASSIGNMENT Ar BASIC HOUSING (CHECK ONE) B. BUNK ASSIGNMENT (CHECK ONE) X l. NO RESTRICTION .__ l. NO RESTRICTION __ 2. SINGLE CELL ONLY 0 2. LOWER ONLY __ 3. SPECIAL HOUSING (HOUSING WITH LIKE MEDICAL CONDITION __ 5. EXTENDED MEDICAL HOURS 4. CELL BLOCK ONLY §_ ROW ASSIGNMENT.(CHECK ONE) . D. WHEELCHAIR USE (CHECK ONE) NO RESTRICTION l. NO RESTRICTION 1.

T 2. GRoUND FLooR oNLY : 2. PHoP oRDERED _ 3. UTILITY USE III.WORK ASSIGNMENT/RESTRICTIONS (CHECK ALL THAT APPLY) 1. MEDICALLY UNASSIGNED __ 15.NO FOOD SERVICE __ 2. PSYCHIATRICALLY UNASSIGNED 00 16.NO REPETITIVE USE OF HANDS __ 3. SEDENTARY WORK ONLY __ 17.NO WALK WET/UNEVEN SURFACES __ 4. FOUR HOUR WORK RESTRICTION 00 18.DO NOT ASSIGN TO MEDICAL __ 6. EXCUSE FROM SCHOOL __ 19.NO WORK IN DIRECT SUNLIGHT 71 LIMITED STANDING OO 20.NO TEMPERATURE EXTREMES 8. NO WALKING > 200 YARDS 21.NO HUMIDITY EXTREMES 9. NO LIFTING > 005 LBS. 22.NO EXPOSURE TO ENVIRONMENT POLLUTANTS 23.NO WORK WITH CHEMICALS OR IRRITANTS ll.NO REPETITIVE SQUATTING 24.NO WORK REQUIRING SAFETY BOOTS lZ.NO CLIMBING 0 25.NO WORK AROUND MACHINE WITH MOVING PART 13.LIMITED SITTING __ 26.NO WORK EXPOSURE TO LOUD NOISES 14.NO REACHING OVER SHOULDER lO.NO BENDING AT WAIST O IV. DISCIPLINARY PROCESS (CHECK ONE) X A. NO RESTRICTIONS ' B. CONSULT REP OF MENTAL HEALTH DEPT BEFORE TAKING DISCIPLINARY ACTION __ C. CONSULT REP OF MEDICAL DEPARTMENT BEFORE TAKING DISCIPLINARY ACTION V. INDIVIDUALIZED TREATMENT PLAN (CHECK ALL TTHAT APPLY) X A. NO RESTRICTION __ C. MENTAL HEALTH REPRESENTATIVE REQUIRED B. MEDICAL REPRESENTATIVE REQUIRED VI. TRANSPORTATION RESTRI TIONS (CHECK ONE) X A. NO RESTRICTION __ C. WHEELCHAIR VAN B. EMS AMBULANCE __ D. MULTI-PATIENT VEHICLE(MPV) WILLIAMS, BETTY MD 08/07/2014

PRINTED NAME AND TITLE OF REVIEWER DATE SIGNATURE'OF REVIEWER /4{){)_§¢/\({;` )\ we inn