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c:\users\tmccoy\local settings\temp\182408778.tif printed by mivap. (Page 1 of 1)

^Scarineg by HAWKS. BEVERLY A. in facility CLEMENTS (BC) on 07/26/2012 08:15

ML00046 /BCM3/HS05 TEXAS DEPARTMENT OF CRIMINAL JUSTICE

HEALTH SUMMARY FOR CLASSIFICATION

12:09:46

07/20/2012

NAME: BUI,PHU XUAN P U L H E S

TDCJ#: 00830601 SID#: 04465764

UNIT: BC HOUSING: 7I32-61B

JOB: GARDEN SQ 15

DOB: 07/06/1961

WGT: 156 LBS

HGT: 5'04" 2 2 1 1 1 2

B B A A A B

P P T

I. FACILITY ASSIGNMENT (CHECK ONE)

X A. NO RESTRICTION

__ B. BARRIER-FREE FACILITY

__ C. SINGLE LEVEL FACILITY

D. SUITABLE FOR TRUSTEE CAMP? X YES_

II. HOUSING ASSIGNMENT

A. BASIC HOUSING (CHECK ONE)

X 1. NO RESTRICTION

2. SINGLE CELL ONLY

3. SPECIAL HOUSING (HOUSING WITH

LIKE MEDICAL CONDITION

4. CELL BLOCK ONLY

C. ROW ASSIGNMENT (CHECK ONE)

X 1. NO RESTRICTION

2. GROUND FLOOR ONLY

NO

III.WORK ASSIGNMENT/RESTRICTIONS

MEDICALLY UNASSIGNED

PSYCHIATRICALLY UNASSIGNED

SEDENTARY WORK ONLY

FOUR HOUR WORK RESTRICTION

EXCUSE FROM SCHOOL

LIMITED STANDING

NO WALKING > YARDS

NO LIFTING > LBS.

10.NO BENDING AT WAIST

11.NO REPETITIVE SQUATTING

12.NO CLIMBING

3.LIMITED SITTING

.NO REACHING OVER SHOULDER

D.

1.

I 2,

3,

ASSIGNMENT (CHECK ONE)

RESTRICTION

LOVER ONLY /

EXTENDED MEDICAL HOURS

WHEELCHAIR USE (CHECK ONE)

NO RESTRICTION

PHOP ORDERED

UTILITY USE

(CHECK ALL THAT APPLY)

15.NO FOOD SERVICE

16.NO REPETITIVE USE OF HANDS

17.NO WALK WET/UNEVEN SURFACES

18.DO NOT ASSIGN TO MEDICAL

19.NO WORK IN DIRECT SUNLIGHT

20.NO TEMPERATURE EXTREMES

NO HUMIDITY EXTREMES

NO EXPOSURE TO ENVIRONMENT POLLUTANTS

NO WORK WITH CHEMICALS OR IRRITANTS

NO WORK REQUIRING SAFETY BOOTS

NO WORK AROUND MACHINE WITH MOVING PART

26 .NO WORK EXPOSURE TO LOUD NOISES

DISCIPLINARY PROCESS (CHECK ONE)

A\ NO RESTRICTIONS

B.) CONSULT REP OF MENTAL HEALTH DEPT BEFORE TAKING DISCIPLINARY ACTION

C/ CONSULT REP OF MEDICAL DEPARTMENT BEFORE TWING DISCIPLINARY ACTION

INDIVIDUALIZED TREATMENT P!

A. NO RESTRICTION

B. MEDICAL REPRESENTATIVE (REQUI

ICK ALL TTHAT APPLY)

MENTAL HEALTH REPRESENTATIVE REQUIRED

VI. TRANSPORTATION RESTRICTIONS (CHECK ONE)

X A. NO RESTRICTION C. WHEELCHAIR VAN

B. EMS AMBULANCE D. MULTI-PATIENT VEHICLE(MPV)

DAVE PA 07/20/2012

PRINTED NAME AND TITLE OF REVIEWER DATE

j< rwt fr-c SIGNATURE OF REVIEWER