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                      Texas Department of Criminal Justice                                          OFFICE USE ONLY

                                                                                            Grievance #:

                          <STFP 1                        OFFENDER                           Date Received:.
                          O 1 SLr 1               GRIEVANCE FORM
                                                                                            Date Due:

                                                       k                                    Grievance Code: .
                                    o
       ip^mme:
 Offender-Name         v^ i^Xh                              TDCJ   #_dbmM2\                 Investigator ID #:

 Unit                             housing Assignment:                                       Extension Date:

  Unit where incident occurred:                                                             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)?            ^T[<rr£Zfo        frj)V%ftW                     When?

 What was their response?                 VJD^\uOC
 What action was taken?                 Jb0G
 State yourr 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
                                                                                                           OFFICE USE ONLY

                           Texas Department of Criminal Justice                                   Grievance #:

                                                                                                  UGI Reed Date:

                        STEP 2                                 OFFENDER                           HQ Reed Date:.
                                                    GRIEVANCE FORM
                                                                                                  Date Due:

 Offender Name:.                                              TDCJ#JMM.                           Grievance Code:.

 Unit:     %MftJDV\^V               Housing Assignment:         C-~ \ 'b —?J~> -"f?               Investigator DD#:.

 Unit where incident occurred:          KlfvLlX Un> yr                                            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 may not appeal to Step 2 witha Step 1 that has 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                                                           (OVER)

                                                                                                                                                 Appendix G
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          CHRISTOPHER A. PRINE
       CLERK.
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Offender Signature   : VO                                                            Date: Crtfo^flUS
Grievance Response:




Signature Authority:

Returned because:      *Resubmit this form when corrections are made.                          OFFICE USE ONLY
                                                                               Initial Submission              CGO Initials:.
LJ 1. Grievable time period has expired.                                       DateUGIRecd:

LJ 2. Illegible/Incomprehensible.*                                             Date CGO Reed:

                                                                                 (check one)     Screened     Improperly Submitted
LJ 3. Originals not submitted. *
                                                                               Comments:
LJ 4. Inappropriate/Excessive attachments.*
                                                                               Date Returned to Offender

LJ 5. Malicious use of vulgar, indecent, or physically threatening language.   2"1 Submission                CGO Initials:

                                                                               DateUGIRecd:
LJ 6. Inappropriate.*
                                                                               Date CGO Reed:

                                                                                 (checkone)      Screened     Improperly Submitted
                                                                               Comments:

CGO Staff Signature:                                                           Date Returned to Offender:

                                                                               3d1 Submission               CGO Initials:

                                                                               DateUGIRecd:

                                                                               Date CGO Reed:

                                                                                 (checkone)     Screened      Improperly Submitted
                                                                               Comments:

                                                                               Date Returned to Offender:



1-128 Back (Revised 11-2010)                                                                                Appendix G
                                 8fo frM B AvW? kg ft
Action Requested to resolve your Complaint,

^n^^rtp^'o                                                                                                                                         ^YxV^rto
Offender Signature:                   YO-MXK                                                                                    ggjnjg^
Grievance Response:




Signature Authority:                              ,                                                                                        Date:
If you are dissatisfied with the Step 1 response,you may submit a Step 2 (1-128) to the Unit GrievanceInvestigator within 15 days 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 1 every7 days. *                                                                          OFFICE USE ONLY
                                                                                                             Initial Submission            UGI Initials:
Q 3. Originals not submitted. *
                                                                                                             Grievance #: .
I 14. Inappropriate/Excessive attachments, *
                                                                                                              Screening Criteria Used: _
|~1 5. No documented attemptat informal resolution. *
                                                                                                             Date Reed from Offender:
n 6. No requested reliefis stated. *
                                                                                                             Date Returned to Offender:
n 7. Malicious use of vulgar, indecent, or physically threatening language. *
                                                                                                             l^SHbjnissifia                UGI Initials:.
T~l 8. The issue presented is not grievable.                                                                 Grievance #:                               . -
f~l 9. Redundant, Referto grievance #                                                                         Screening Criteria Used:
l~l 10. Illegible/Incomprehensible. *                                                                        Date Reed from Offender:
C] 11. Inappropriate. *                                                                                      Date Returned to Offender:

UGI Printed Name/Signature:                                        -                                         S^ubmission                   UGI Initials:.
                                                                                                             Grievance #:
Application of the screening criteria for this grievance is not expected to adversely                        Screening Criteria Used:
Affect the offender's health.
                                                                                                             Date Reed from Offender: _
Medical Signature Authority:                                                                                 Date Returned to Offender:


1-127 Back (Revised 11-2010)
                                                                                                                                                              Appendix F
