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Texas Department of Criminal Justice

STEPl

OFFICE USE ONLY

OFFENDER

GRIEVANCE FORM

Offender Name: S.-7. ^ TDCJ #

Unit: Housing Assipnment:^^^/g '̂t>?'̂ ''̂ / "2 3~^Unit where incident occurred: A') /T.

Grievance #:.

Date Received;.

"^ateDiie: r

Grievance Code: .

investigator ID

Extension Date:

Date Retd to OiTender;.

You must try to resolve your problem with a staff memberbefore you submit a formal complaint. The onlyexception iswhenappealing the results of a disciplinary hearing.\Vhodi(itwwtdV<1bA0iifi:,title)? lA/n f 'M When? //^/ 'Zy-^/^C'JCWhat was their response? A<

What action was taken? AJtJJr'. Of>. Tr-"* • A -NOV n ? 2015

State your grievance in the space provided. Please state who, what, when, where and the disciplinary easenumber if appropriate

On

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1-127 Front (Revised 11-2010) YOUR SIGNATURt IS REQUIRED ON BACK OK THIS FORMi

HOVER)

Appendix F

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Action Requested to resolve your Complaint.

Grievance Response:

Signature Authority:

Ndv 0 2 2015

^ 'yi/{ A/r-T" y^ye-y j X"/: '̂rJ--^/O y'~/% y//'•t•^u^y^y^T'—y^/yy A/^y.-p • y'C'./ny^

Offender Signature:^ Date: /' C-/yttUf

Date:Ifvuu arcdi«sativlicd »iththc.Slcp I response.)you may submit 8Slep 2(1-128) (o the Unit Grievance Investigator nithin 15 days from the dale ofthe Step I response.Stale the reason for appeal on the Step 2 Form.]

Returned because: *Resubmit this foym when the corrections arc made.

• l Grievable time period has expired.n 2. Submission in excess of I every 7days.f~l 3. Originals not submitted. •

• 4. Inappropriate/Excessive ultachments.r~l .5. No docuinenled attempt at infcnnal res:

• 6. Norequested relief is slated. *

• 7 Malicious use ofvulgar, indecent, or piVsically threatening language.n 8. jrhgiinHie'prdSehte'J'is not ^evableiyi 9. Redundant, Referiogrievance

si

Q 11! Inappropfiaie. ^

ij\ UGI Printed Name/Signature:

ilution.

Application of tlie screening criteria for this grievance is not expected to.adverselyAffect the offender's health.

Mcdicai Signature Authority:.

1-127 Back (Revised 11-2010)

OFFICE ^SE ONliiilini :>tibtnission luGI Iniiials

Grievance #:

Screening Criteria Used:

Dale Reed from Offender;wmrrn

-NOV 0 2 2015Date Returned lo Offender:

Z'̂ &MlUBiSSimi -UCI Initials:.Grievance #:

Screening Criteria Used:

Dale Reed from Offender:

Date Returned to Offender:

au-aiUunihSM uci initials:.

Grievance S:

Screening Criteria Used:.

Date Reed from Offender:

Dale Returned lo Offender:

Appendix F

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TIT

LE

:A

DM

IN