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## c:\users\tmccoy\local settings\temp\182408778.tifprinted by mivap. (Page 1 of 1) ^Scarineg by HAWKS. BEVERLYA. 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
P U L H E S NAME: BUI,PHU XUAN 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.DONOT 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< rwtfr-c SIGNATURE OF REVIEWER