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Texas Department of Criminal Justice

<STFP 1 OFFENDER

O 1 SLr 1 GRIEVANCE FORM

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Offender-Name

Unit

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housing Assignment:

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Unit where incident occurred:

OFFICE USE ONLY

Grievance #:

Date Received:.

Date Due:

Grievance Code: .

Investigator ID #:

Extension Date:

Date Retd to Offender:

You must try to resolve your problem with a staff member before you submit a formal complaint. The only exception is when

appealing the results of a disciplinary hearing.

Who did you talk to (name, title)?

What was their response?

What action was taken? Jb0G

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State your grievance grievance in the space provided. Please state who, what, when, where and the disciplina

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1-127 front (Revised 11-2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM (OVER)

Appendix F
Offender Name:.

Unit: %MftJDV\^V

Texas Department of Criminal Justice

STEP 2 OFFENDER

GRIEVANCE FORM

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HousingAssignment: C-~ \ 'b —?J~> -"f?

OFFICE USE ONLY

Grievance #:

UGI Reed Date:

HQ Reed Date:.

Date Due:

Unit where incident occurred: KlfvLlX Un> yr

Grievance Code:.

Investigator DD#:.

Extension Date: _

You must attach the completed Step 1 Grievance that has been signed by the Warden for your Step 2 appeal to be

accepted. You maynot appeal to Step 2 witha Step 1 thathas been returnedunprocessed.

Give reason for appeal (Be Specific). / am dissatisfiedwith the response at Step 1 because...

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1-128 Front (Revised 11-2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM

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(OVER)

Appendix G
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CHRISTOPHER A. PRINE

CLERK.

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Offender Signature: VO

Grievance Response:

Signature Authority:

Returned because: *Resubmit thisform when corrections are made.

LJ 1. Grievable timeperiod has expired.

LJ 2. Illegible/Incomprehensible.*

LJ 3. Originals notsubmitted. *

LJ 4. Inappropriate/Excessive attachments.*

LJ 5. Malicious use of vulgar, indecent, or physically threatening language.

LJ 6. Inappropriate.*

CGO Staff Signature:

1-128 Back (Revised 11-2010)

Date: Crtfo^flUS

OFFICE USE ONLY

Initial Submission CGO Initials:.

DateUGIRecd:

Date CGO Reed:

(check one) Screened

Comments:

Improperly Submitted

Date Returned to Offender

2"1 Submission CGO Initials:

DateUGIRecd:

Date CGO Reed:

(checkone) Screened

Comments:

Improperly Submitted

Date Returned to Offender:

3d1 Submission CGO Initials:

DateUGIRecd:

Date CGO Reed:

(checkone) Screened

Comments:

Improperly Submitted

Date Returned to Offender:

Appendix G
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Action Requested to resolve your Complaint,

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Offender Signature: YO-MXK ggjnjg^

Grievance Response:

Signature Authority: , Date:

If youare dissatisfied with the Step 1 response,you may submit a Step 2 (1-128) to the Unit GrievanceInvestigatorwithin 15days from the date of the Step 1 response.

State the reason for appeal on the Step 2 Form. ———^————n-nmw——~ '• a—— —^— ~~^——^—i ^ ^—f^—— ^gsa=ganHHHHHHHHHzHHHHHHHHBBaeaBsjBgs=^=

Returned because: *Resubmit this form when the corrections are made.

[~11. Grievable time period has expired.

I~l 2. Submission in excess of 1every7 days. *

Q 3. Originals notsubmitted. *

I 14. Inappropriate/Excessive attachments, *

|~1 5. No documented attemptat informal resolution. *

n 6. No requested reliefisstated. *

n 7. Malicious useof vulgar, indecent, or physically threatening language. *

T~l 8. The issue presented is not grievable.

f~l 9. Redundant, Referto grievance #

l~l 10. Illegible/Incomprehensible. *

C] 11. Inappropriate. *

UGI Printed Name/Signature: -

Application of the screening criteria for this grievance is not expected to adversely

Affect the offender's health.

Medical Signature Authority:

1-127 Back (Revised 11-2010)

OFFICE USE ONLY

Initial Submission UGI Initials:

Grievance #: .

Screening Criteria Used: _

Date Reed from Offender:

Date Returned to Offender:

l^SHbjnissifia UGI Initials:.

Grievance #: . -

Screening Criteria Used:

Date Reed from Offender:

Date Returned to Offender:

S^ubmission UGI Initials:.

Grievance #:

Screening Criteria Used:

Date Reed from Offender: _

Date Returned to Offender:

Appendix F