MICHIGAN DEPARTMENT OF CORRECTIONS 

PRISONER/PAROLEE GRIEVANCE FORM 

Date Received at Step I /I I ,-, Grievance Identifier.

-

4835-4247 10/94 

CSJ-247A 

I f 1 ] 

Be brief and concise in describing your grievance issue. If you have any questions concerning the grievance 

procedure,r-"cr •o,PD 03.02.130 and OP 03.02.130 available in the prison Law Library. 

Name (print first, last) Number Institution Lock Number Date of Incident Today's Date 

What attempt did you make to resolve this issue prior to writing this grievance? On what date? -----'l,�-�-----­

If none, explain why. 

\ 

J 

State problem clearly. Use separate grievance form for each issue. Additional pages, using plain paper, may be used. 

Four copies of each page and supporting documents must be submitted with this form. The grievance must be submitted 

to the Grievance Coordinator in accordance with the time limits of OP 03.02.130. 

,. ' l 

1 

. l

Grievant's Signature 

RESPONSE (Grievant Interviewed? DYes �No If No, give explanation. If resolved, explain resolution.) 

Respondent's Signature 

Respondent's Name (Print) 

Date Returned to 

Grievant: l"'I 

Date 

Working Title 

If resolved at Step I, Grievant �gn here. 

Resolution must be described above. 

Reviewer's Sign�ture 7 

/ I /1

Reviewer's Name (Print) 

Grievant's Signature 

DISTRIBUTION: White, Green, Canary, Pink - Process to Step One; Goldenrod - Grievant 

,, ,/,,), Date 

Work(ng Title 

Date 

Exhibit 2 - Roman's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-3, PageID.7246 Filed 06/06/18 Page 1 of 5
Michigan Department of Corrections 

GRIEVANCE REJECTION LETTER 

DA TE: 7/7/17 

TO: ROMAN LOCATION: SMT 33-3-A 

FROM: Grievance Coordinator: Chris Whitford FOR STEP I 

SUBJECT: Receipt/Rejection for step I grievance. 

Your step I grievance was received in this office on 7-7-17 and was rejected for the following 

reason. The content of policy or procedure is non-grievable. 

PD. 04.06.150 States in part L. L. Routine' dental" services shall be available at all 

correctional facilities except reception facilities. However, routine dental services 

shall not be provided to offenders in the Special Alternative Incarceration Program 

and may be denied to any offender who may be released from incarceration (e.g., 

parole or discharge) within one year. Offenders are eligible for routine dental 

services after 24 months from the first day of intake. Only the following routine dental 

services shall be provided by the Department in correctional facilities: 

1. Minor oral surgery, including extraction of teeth beyond repair. Surgical

cases beyond the scope of Department Dentists shall be referred to the

appropriate specialists.

2. Restorative services which includes amalgam and composite materials.

3. Teeth cleaning provided by a Dentist or Dental Hygienist, when determined

necessary by the examining Dentist.

4. Prosthetic services as determined by the Dentist. The DAB shall establish

criteria for the provision of these services.

If you have a concern with the content of a policy or procedure, you may direct comments to the 

Warden's Forum as provided in PD 04.01.150 "Prisoner Housing Unit Representatives/Warden's 

Forum." If you have any questions. consult PD 03.02.130 uPrisoner/Parolee Grievances" which 

is available in the institutional library. Grievance is rejected at step I. 

Any future references to this grievance should utilize this identifier: SMT 17-06-726-27B 

Roman's Dental, kites 

Exhibit 

& responses, grievance 7 

2 - Roman's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-3, PageID.7247 Filed 06/06/18 Page 2 of 5
1 •· . 

MIOIIGAN DEPARTMENT OF CORRECTlONS 4835-4248 5/09 

PRISONER/PAROLEE GRIEVANCE APPEAL FORM · CSl•2478 

at 

Date 

Step 

Received by 

ll: ____ 

Grievance _ Coordinator Grievance ldentlfl�ITIIll j]l<14r)() I/ l,d"Q)JJQ 

The 

INS11WcrlONS: 

white copy of the 

THIS FORM 

Prisoner/Parolee 

IS ONLY 

Grievance 

TO BE USED 

Form 

TO APPEAL A 

CSJ-247A 

��ll&lWl;L.�-"t'�-:1. .... have not been proVlded 

with a Step I response In a timely maMer) MUST be attached to you appeal It at both Step 

II and Step m.

lf�-11>-1tlleS!sp$-"'- L::{}O O by • If It Is not su

Office, 

If you should 

P.O. Box 

decide 

30003, 

to appeal 

Lansing, 

the 

Michigan, 

response you 

48909. 

receive at Step n, you should send your Step Ill Appeal to the Director's

��0,C fi Name (Prtnt) 

�Pm·-Reason for Appeal 

. � 

�.-l,t°". 

�" �u:oua neeo tJf ��- �, o.u.t. --\o .,.,..y he.\-l i-4' 

tAy t.M.c..e:r� Cl.l\Q ..,,�� t.AlU-t- "-Ot n-so\ v.� .l:t\ skf Ct\A... or S\."f �o. 

NOTE: Only a copy of this appeal and the response will be ratumed to you. 

STl!P m - Director's Response Is attached as a separate sheet. 

DISTRIBUTION: White �$teP,IUA G�,

, �f!Y, Plr)l< - Process to Step II; Goldenrod - Grlevant 15-ubn1a , Kites & responses, grievance 9 

Exhibit 2 - Roman's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-3, PageID.7248 Filed 06/06/18 Page 3 of 5
Step II Prisoner/Parolee Grievance Reaponae 

Prisoner Name: Roman Prisoner Number. 250050 

Grievance Identifier Code: SMT-2017-08-00728-278 

STEP-I FINDINGS 

The grievance was rejected at Step I, the content of policy or procedure la nongrievable. Per PD 03.03.105 a prisoner is not entitled to a Hearing Investigator for a 

Class II misconduct. 

If you have a concem with the content of a policy or procedure, you may direct 

comments to the Warden's Forum as provided in PD 04.01.150 •Prisoner Housing Unit 

· Representatives/Warden's Forum•. If you have any questions, consult PD 03.02.130

•Prisoner/ Parolee Grievances• which is available in the institutional library. Grievance is

rejected at Step I.

FINDINGS 

The Step I rejection has been reviewed by the Warden's Office in accordance with PD 

03.02.130 •Prisoner/Parolee Grievances• and the REJECTION IS UPHELD AT STEP II. 

Signed: {\A, q_,l.,,.., b-,4 ,. 1'.., 

Melinda Braman, Warden 

Date: 7/13/2017 

Roman's Dental, kites & responses, grievance 8 

Exhibit 2 - Roman's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-3, PageID.7249 Filed 06/06/18 Page 4 of 5
RICK SNYDER 

GOVERNOR 

ST,-1. l"E OF l\4JCHIG.<\N 

DEPARTMENT OF CORRECTIONS 

L.-1.NSTNG 

STEP III GRIEVANCE DECISION 

To Prisoner: Roman 

'/l--.-1

Current Facility: _.J , • I 

Grievance ID #: SMT-17-06-0726-27B 

Step ill Received: 8/8/2017 

#: 250050 

HEIDIE. WASHINGTON 

0111111CTOR 

91806 

27B 

Your Step ID appeal has been reviewed and considered by the Grievanc S ct ion of the Offic of 

Legal Affairs in accordance with PD 03.02.130, "Prison r/Parol Gri vane " 

THE REJECTION IS UPHELD. 

THIS DECISION CANNOT BE APPEALED WITHIN THE DEPARTMENT. 

Richard D. Russell, Manager Grie, ancc 

Section, Office of Legal Affairs 

..-.­

cc: Warden, Filing Facility: 5 /11 £ 

Date Mailed: AUG 31 2017 

GRANDVIEW PLAZA• P.O. eox 30003 • LANSING, MICHIGAN 000[1 

Roman's Dental, kites & responses, grievm,me, 2 5 2017 

Exhibit 2 - Roman's Grievance

Case 2:14-cv-11691-LJM-MKM ECF No. 249-3, PageID.7250 Filed 06/06/18 Page 5 of 5