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06-1299
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CSC _ ;-- C 21 cj-k (Clt 02? - T l ce, ??l'v r n? ) h(- kC?-- -Oal ?t C. e-) v\y 4?l l? _ 7 LA 2 Q?? -r -?1C (a` 0 91? <?(2rl (cq?2C ? Jc? 1.?Ll? C L ,. . , CCj ?? ?- 5?-k? c`S ? ° I t`C?l? {C_ C, 4 ?, Cam- u?' P?`P .nom __f ?? J 07)) (C-) L? G:: 'U G F' S,q, ?F Aol? LSSCC c? . ,4r e. aV7 - ? ? ,_ `,?. _.??- ?.: ?-?' ''`_ ` t`---_ `ter,.-? ?'?`°W:- ?? -?---- t? ?„x.? ?? v a ? ? V _ -?-?M t 't [jay ? ? ?.? -?= ' r' i ? C\?y ? p?j ?1 .?."-rR?? -^•?? ?: 5 ?- DC-B04 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE '- T ..FAGZK FACILITY DA E: FFOfvl f (INMATE NAME;`: NUMBED S4GNA q RE of INMATE m f r . W RK ASSIGNMENT'- ' I " vtEN HOUSING ASSIGN L NSTRUCTIOI` s? l 1.---f? ? _. ? . - ?!9's7r`?bi?f?TCe1?II??II?ff?A??`??.?rll?afit&r?"Y'? ?--._..J ?,.,,; •.._; 3. List in Block B any actions you may have taken to resolve this matter. Be sun= to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, maximum t w pages. o (One DC-804 Part 1 form and one, one-sided 81/2' x 1 P' page) Q' Z `? k t t ? c4-yam V1t'?,-? ti a'..1 " _, ??t. C.tW{ p 1F 1 r? t n., _ ( `-,?1 r) n { o- ?? ?y??iGZ,,, ?? } il,.cL, t„?c f,--t• r 1??F...4 t ?S ' -??. ,Q 4> r -??C ? ? t ?.:. ?:.??r r\ ,c r Y.? inGV ?- 1. 1 'e^, yf'_.l-•.C 'd le y`-y ..' e. ? '4 •`? 4 . l k 1 T1 / c.L a:4 mow.: G. ' t ? Y c.+ l t' C. S.x ?S .w • F xh. ,:tFl '?T .L ?i_3 t f 1 " `A3T h ' , '^ ' 1 , -..,.g ...e. t? 4? h?- *. -- ?? ?- t. L tz ,- C....:F-+-. .,.34- A.4 ,N .tJZj iv, V.!^-3 C?CC.."a'. Y S?;J?'L l6`+r?!.h?-[i`CSs-1;.3,.r?(Lb ?-C"F.d- f E t r'"• (? ? ? n'?c to .\ S, ?. l?ut? .s:C_?sr, . r? `2 .F~: T? , • . , _ - • ti 7 1.7 , 7 77 c..,, '. 777 ,L 7 '77% 77k _ p u Ci f 1 C t' C ' r .. . ...- ? .. ?. l?.hi_ . t?n, CC G? r_?` { ?.- AL.'S ..?- ._, - t - 4 f , V tS >dC (r k c?.y? ti? vw t c! F^.tiG c l .c; t L ?' "( ' , F vk ?? .. % ? . \ H .`cam - ?d? E 1c c _.( ?? f' ? T?` i ^M•`L t .z! ..,.. •- -?.. `tea " 5 iw cl:.r B. List actions taken and staff you have contacted, before submitting this grievance. (' -`_ Y?C..6-sue l S. V..Yi- R h [ -?+.L4. `r.• }.)'Cl , ,`._ 7- P3, l +F vc. A C._t l r12?C<v 4? J e C' mGij s; e _ y. Your grievance has been received and will be processed in accordance with DC A,DM $04. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised C DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 .DEPART, AEJN 0Er", 1Q,f3i3E0ML4S? CAA?f ,?t?'' _ --459a,?'^ GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE ?%A' TO F Q " ;I m :.-.. f e E ,FACILITY: DATE,, < r E t: (INMAT NAM NUMBER _ \\ tr FRO t,SiGI TU7E of INMATE:) y t ? y W?OR,K ASSIGNMENT' HOUS X4SSIG MENT' - f t ? V ` om. C`•d \..?fKr, Y 4! .N ._l.1° 4'^E?P E lYv gG :.-I ["?. 1 lW v.t F 145 V INSTRUCTIONS: -- t C ` 1 ?;6afer?fc?fla r»,,t ura??.aar;tacedares?ota?b?amaiga7?v??a??sysi_ern. ' ?--.?? _ 2. SYiZa?r?ctrle?auaaadr6'l'dlha a brii<i apr> erlablei,Qaanraer 3. List in Block B any actions yowmay have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper 81/2" x 11" page). may be used, maximum two pages. (One Part 1 form and one, one-sided / ?`!!+Fn l?S C; ? `-?'?t•.' 'r'".{'e•°"t"`(.:.. t?t0^_?.Y?S11S [ \+,.LJ.S?u'.r?\.?" ?.'..Y?,it ?e4,?rSuf'? A. ??6lr....-ti'. 1 , ` / 1 i - ` _ +iY Fv6 st? f?Rti ( r.^?G??R•dkF b•?40 .?. .C`t"Jf w ?4.Et"?M1?Srs ,,.,tr•t.4. rRi-e ?.rea n-'v:JCN t C-T' ?-? ' ?"r,,.\?1.. N . wk l ?l?tF 't caS- a ?i?h.?*? ?« 4?rF{ f.C .L._.•?..:.?. '? `-?-tvti-mac ?''?Cr-a-.1 Ya.`# ?i;"i?.T_:? ?-T'i. C.?ti`. ?cu 'bi.i?.1(t) 'd`?l -.C? a f F..? 7 ?4 L ? - 4 - 1 • .`G' a _ ...cm} ? E5 S 7 V 1 1 ..fly a,??e F??.cC..b..t S_ tc Nl?'E-. fi 4.t ::' k-1 G ,'?•. u?vSht ^"- .. . .., W \ Lam!.-E-?f-P` QN/rC e i` .. `1 E.JC t?.? ..'. 1 `+(r t3-'•: hl =d--Sys A'?a..-1C'iC d_.CP COY f..' `tom 1 t,"`tsak \ J Lh-^..„ Y k?^ aM1-..C'•ds?.:, g4'tid? ?C' C:??,.r` 4S 4=-." t hl ' ? 4 - . 4tilC . h " / Z p ? ? \ c ` , . c C tes t nC lot kc, z.C c:??et v Er r h'r l=r,C -d s? c ? U`S ` „ f .,F-:q..i !3Cic'.C.IJv ti..k?Ci M-?J hz'C? .-t^., `.'-.l-VC.ia't?.:?YJ=i=ce,, N \ . \`_.. <'?.t+.A? t+-??} Y'wht` +i f• t....'N•vhc ???...+..3.?.r•yZ?S ?`? \.•.?._ ?tiL?a i?_1-1. a-1? ?i r... \ . C?. .[ '^/ ` y 7-7 7 ..... . F ?,.C i +,•a_C rt :{ F? ?, r-? ?';C., ?C'?.'.? Y'•??1C"..f i 77 L ` ` ^ ` t •e . ?.1 . _? d A „ B. List actions taken and staff you have contacted, before submitting this grievance. i v- ai??`s? tz ',4 i ;-a- .. 1?•' *` PAC'-?'?:-`.c,TJ,y ?C (?ri - r? -.c- _ Tv`•-- --Z' k' t..Y-1 C,:i. w 'K C" •.5,. a 777' (- A„ F't v?r??:C a "t (-\/l• I., •,...? .`?. rt` ac.. rL'-.. (-`a...':.'? -•.. ,..:,h "Z 7',77-2-77 ?? 4 ,, ? rs ? 1 i'? i}. ? ?? t+§ 4hJ .. Z N? \J C._. `\,t }7'-\ /Ifi:c fy. Y 0 ,. t??.?r : ' l^ ? !?,?`-+- ??r ? ?_ '"? ?d,? y?•. t"A? A !' r?.•-. 9 A 'p?.U ?C Cti._i bw (!'y '? t r ? C- t Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised t 7 A 4 COMMONWEALTH OF PENNSYLVANI FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS P. O. BOX 598 CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER O PPICIAI INM ATE ln'131^`-Alit •'' 1. 4, .6 `A r" c-.. Ta-r-Ac-U10 ffiWIRM 13DINAT H J EA?CII ITY c- _ -- DATE t ? ? FROM: (INMATE NAME'S N MBER) t• ? 1 } ST(??IATU E of INMATE: ? ? f ' - y vV.j e L..;?.:?t+''? t?\ : i ?` •,, SIGN WORK A ? T: i EN ` HOUSINGASSIGNMENT: l INSTRUCTIONS: 1. -M -f§r tt +1M8 Gx ${31 9rk #x>r Cd d°r f mID'3tL gue arsce 5lJStem. 2. 6ta4eryoGgrar?taci? BJeJ:ir?brar7 -r 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper Part 1 form and one, one-sided 8'/2" x 11 page) y h „ . (One DC-804 wo pages may be used, maximum t ( ( td v &PIN oaf ai'+EkJ" '""' -- t ` ? ? rrk } E.t '?.? is'l-. ?:.,'•?? Ys?.. iyC: hg' WEB 1_.'"s"'.ii ,•? . `k r?e^ C ks,?.. uE'l,? d t " S.y,-?' ?r'--rw. ? . . n k.-S ?.,..!^ \'T'vk (\?.?* :l $. " -at!'2 '?'ii' ^ - Fh.i'`..r,, i `a•'t'"=.L.+<j,-ui, ." C.D'..t.. n1 f-r"Z?v. `" ,. " = aa. t 7 477? -( c:) _2775 TM 7_ r n c 1--'C rs.r (..hS 1 t,.. SC.L? !-r,( .1 yT ? tt+t} t_.!F-k?. i? ,:c ? t. 't v ^ t l Y. -, (_- 3+ ! .? its :~i F 4 ("'-.+a : ?:-•SFt ?•` ? "' ` ` f 4 , . ... 4 C/ ` ,.f"L??° ?t C.. ? ft LA-><<(? t-•..?,?.- i c..'. ? l ?,.?;?z? e ( ???? W •. ht 1 Ct Al t•a k i -+ ' 7. T- !n . "F-- G r , 1 CS_-L E ? L`^? lC r:C- -. ?"y • ?:._. 7 ' O 'li t A r . {?" titi? ??`t E?`.r...5v,%? .c?s??su""51f_ r-}'.'__a ?^ C )? ! ?'"" :f r,.l ` c - v x- :,,K- trtr_ sc s F-c +...?4: _.A^.. .-r?.?' <?? X62 ill.`.? "4 C"';.i??- :i:J ? "f• 1'tt? ?e..l l..F N t..?.`t-'?.Y?LJ 4, v1' Gw::'.% l?.ti. -'S ?hilL ..t n =- B. List actions taken and staff you have contacted, before submitting this grievance. i 1 1 (' •.e.Y?+. `..,?•="4 Vt 'tz-_ iit\\ ' r. .:=4 :<'.. -' •7 s__{.,.. ...+i'i.. /A -?"? ?1.P.t.,,,. '-a.1^?t I+.. n ,^.n.-lr?.. : ._.I:'C' \ w }!?i t.W. `. JYi.. t r<" u t--rw: l.:l:? S-.'. Y ? \ I c rc ;v_';r '' , 1.: t ? ' ? w?'C•tl-t C? '". S.x t4 'rt C? k?-f t}„ r t ?+, C L c s-t } n.. a ' ,<. _L ` ' "-` '>,-.e tea , 5 ti r lkh•t I?.ln tt.? Your grievance has been received and will be processed in accordance with DC-AlM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - Fife Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August2004 DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS P. O. BOX 598 CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER OFFICIAL INMATEeC:8 y..A -,S ' ' ``"`' TO. h1 ptj r' f x Z I." FACILITY' - i DATE: t t F • k _ : `A FR INMATE NAMF & , VMBER) f SI %TUR15;of INMATE: t c WORK,ASSIGN ENS:: HOUSING ASSIGNMENT: 6" INSTRUCTIONS: 1.-=R eftr?tote??A+?fal:?taT?pra?G?s???tagriQ:uar,?y§rTa. 2. ?5fah+a=gour?gciea*an?e??it?,BJ??lit??rde#e??:?ersk'?ble?atar?er 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are :seeking. Additional paper ^ may be used, maximum two pages. (One DC-804 Part 1 form and one one-shed 8'/z" x 11 page). @ F f X21 E ?' r''r?'"' a "4 C t ?`°" t f?` ? w i ? • ':^?! ? ?t-1 ? ? ? (C „ . . , .- ?? : _ E,.., f ?r ? ? 6 ? ?(n. ?C-!?E`-'V f 6 l ? .. bi.- f *? hvu- ?? ` ?M?.e ? v 1V ...4 E?c? ?' ?y !l E 41 ; i v? "'? \ k _? ' I,\ \ \ '. ?` (4}tt$ ^? yJ ( l y 5 V4? Ye t ? l..t.sAt C* N+ $?"t? 1 of [? 15 st F 5 +1 ? ' t C y V4 11 `4 l - .. v 1 Y . . .i , ?- + l...\+! { s -. {4 ( ? ,{ ( y \ Q. 3L S? T.: a ` rM?•6.....+?,k / ?? -r t ? -? , ?" ? s } t ? f ? t. s` - ? ..... ue. % ,, ..? ' s/?4 ? i r???ti, {??,^-a, ? T"'•-=? "?i.i ^? ? lc. ?!? "? Y'S !•_..? 1CJ ?? 1?,,} °,.? i-t?? l t Y )CJ ??`? a• ?'? ' : j? ? . . .. s . \ . ,,,., i " ..,... .u ?-*?. z p ?? _F •. ? F >r..-: ,,. ,,rte -? ,i' l -N4e C. ..- - 4C, ti a . } L l C r'? f 4` t, _!4 Ala- C- '-,..t i' t ?9.5 1?- 1 x t-: C t, y? % B. List actions taken and staff you have contacted, beforpa submitting this grievance _ f A ? t EF'4 4t1y" b? a , - t"?P'f'" ° Ihw R 0 ?L2 !l ' } y{"l' ? .._. .._k.-.e: .-r'„C.r L.? si.f?. i £ "li'Z..i? `', t f ...c ?"?t`_r',?;-: Sa.- t._ 1,a ':t j , .L=x_ +??'A ,? ":1..C= n^, .! t ?c •,; ? r? -_Y? a .;'.,? ., ;^ `'. w+:? C,_.<. ? ?4 J M ®? t a. t...l,...r 1 ?.!?? ? :-. a t.. ? r3 iq;- r.. f ? ? t -?: ?P_ e / ? -- ? i 4 r y i .. n , , "ti.a c ? c- 1'k ' V., . 4: t c} `•':,'(? .'? t ?<..,. ` Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised _ ..;;eraiE,S f UEEc ; i ETA IMEMiBER l3eDartm.-_ . of Corrections'-. INSTRUCTIONS Complete items number 1-B. If you follow instructions in preparing your request, it can be responded to more promptly and intelligently. 1. '' To: (Name and?itJe? \f Offs a -- - - I\ 1 .. i 2. Date: r 3. Byam : Print In at N' j Print e?Dd Nut 4. Counselor's Name -- 5. Unit Manager's Name ,Innate Signature 6. Work m 6t i 7. Housing Assignment -ice?-- 8. ub'ect: State our request com I t I but briefly. ive details. n ?i i - 9. Res' onse: lf?is Section for Staff Res onse Onl To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name Date Print Sign Revised July 2000 rv? 4 V 7 2004 DC-1 of Peunsytvania of Corrections INMAT'E'S REQUEST TO STAFF MEMBER - INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more L rom tland intel i enti . 1. To: (NOffi r) andite 2. Cate: t_( , rint mat Nam and Number} 4. Counselors Name 5. Unit Manager's Name mate Si nature - _? -- - _ 6 11W ' ss grim ntJ 7. ou A m t d. (?lect: State yOp7 ec( St comp ? y tP ierly. $ivetiietatlss. (? f ) n r ? l z 9, Response: (?Thyis Section for Staff Response Only} -? -? rln a AMYL eLB.w L To DC-14 CAR only ? To DC-14 CAR and DC-1 S IRS ? Staff Member Name _ Date ` i9 Print -? - Sign Revised Juty 2000 e?J e ad? 11A >?C 135A ` /? ?? otlwealth of Pes nsytvania gEnG Department of Corrections INMATE'S REQUEST TO STAFF MEMBE INSTRUCTIONS Complete items number t-$. If you foilow instructions in preparing your request, it can be responded to more promptly and intelligently. 1. ocer) To: ( me and Ti 2. s=ate: 3. * -B (Pi Inm to ) 4. Counselor's Name 5. Unit Manager's Name Inmate Signature 5. W xA fgriment 7. Housgg Ass nment Z? 3 SubieCt7 State r -ecuest co nDletel• but brefl v= r'-tails. Revised July 2000 1w •e_ //LC t -r 14?f- <?2c --f--- C,C.Z? 1> -onn DC-35A Commo Ith of Pes-,nsyfva . " / ? Department of Corrections 6 - INMATE'S REQUEST TO ST ME R INSTRUCTIONS Complete items number 1-8. N you follow instructions in preparing your request, it can be responded to more promptly intelligently. 1. To: (N and itle of r), 2. Data: 3. Pr'nt nmate ame nd Numb 4. Counselors Name 2-0 -- fi-'? ` 5. Unit Managers Name ee Inmate Si -atur 5_ _ Wor Ass i ent vv?SL 7. Ho s,r. Assignment ? ?? 3. SubiPc Slate y cur •eeuest rrDletel but b e;- . e details. C Staff Member Name Print Date Revised July 2000 t Bonn DG-135A I eivea ' Commonwea of Peannsytvania o X04 Department of Corrections INMATE'S REQUEST TO STAFF M EMB 9 INSTRUCTIONS iN items number 1-8. If you follow instructions n preparing your request, it can be responded to more - promptly and intelligeripy. 1.i To. (N a and Trt1 of ) 2. Date: (Print nmate N e Numb 3. : 4. Counselors Name . e ? 5. Unit Managers Name inmate Sicnature - _ 6 W As ' si nr{;ent ? 7. Housing Assigr:r/?ent Subiect: State r ecu st co oletel but briefly. G ive detaiis. tea, c A- c\ ; c? v 1 C C, - - -- vw 9. ' es onsei is Section a es o Onl - M - A -e h c1 G? To DC-14 CAR on ? To DC-14 CAR and DC-15 IRS ? 6 Staff Member Name Date "v " Print Sign Revised July 2000 ?, o " DC-135A `°??ed 1COrnmorme2 of Permsylvania I ` Department of Corrections M8 . INMATE'S REQUEST TO STAFF ME o INSTRUCTIONS uctions in ll in t f tf 1 13 ow s r you o - . items number - 1 preparing your request, it can be responded to more - - prompffy and intelii entl . I To: (N a and T'id of 2. Cate: 3. ; (Print nmate N e Numbe 4. Counselor's Name Unit Managers Name inmate Slcnatur- -' 5r W" Assi nrfient _ 17. Housing %ssr`rr.ent_?-?? but briefly. Give details. I -? Y \.Q-ey-.? i j 9. `Res onse`. is Section for Staff Res l.. ... ?.:: '. - Onl C -1 c? To DC-14 CAR and DC-15 IRS ? T DC-14 CAR ? To on ' G Staff Member Name Date - Print "? Sign Revised July 20001 - ?? I ? Re C 135A INMATE'S REQUEST TO STAFF MEMBE om wealth of Pennsylvania N? rtmenil of Corrections INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligently. (Nam and Offc 2. Date: ? B . {fit M late N me a Nu er? 4. Co nselor's Name 2??4 5. Unit Manager's Name 'lhrnate Signature 6. Work sign n c 7. Housing ssig ent 8. b'ect: State our request com I "tel but briefly. Give details. i L T I - 77 ?It It, :??- S Q:;S .' 1, ?Section,.gf'?. ? • . '9 _ ?rl '+ .'.. ?, _w.??:r. ? _'°'', - .L4 ? tTT..iC_ G.r?ti°? ?9 s- '?CO•-•-+-. To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name Print° Sign Revised July 2000 Date ( 1:1-y-?,F„r L'i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS SCI-FAYETTE ----? April 27, 2004 --?. SUBJECT: TO: Grievance Appeal # 79382 PEW, Alfonso BT-7263 J-B-2023 --? FROM: Neal K. Mechling Superintenden This correspondence is in regard to your appeal of Grievance # 79382. The Medical Director evaluated you for back pain on 01-30-04. Treatment was provided. QUly Jule rrpdicaf Director c make make a referral for phv eraov. To date, no such order has been written. I concur with Mr. Tretinik, you need to address your concerns through sick call & co-operate with your entire treatment plan when implemented,. Grievance & appeal are denied. NKM:jts CC: Ms. Scire Inmate DC-15 DC-804 Part 1 r ?e "MONWEALTH OF PENNSYLVANIA t DEPARTMENT OF CORRECTIONS P.O.80X 598 CAMP HILL, PA 17001.0598 U"[ ;tai rrvmArc u+acv„r. c T?? FACILI C_ DATE: FRO : NMATE NAME & BER) SI T of INMATE: w0 A SIGNMENT: S G IGNME r: , Y , INSTRUCTIONS: t ym__ 1 oa-.a.'r°,?-.'e^-tom _ rieuaasg-sys 2. , r RPM of staff 3. A. -r- -- G• , A G, o Ct_??{ F e CG,`-?rs,.Y i a CIL ou have??coynta?cted, be ore su ml ing this grievance. B. List actions taken an st i 4, j-r-Eftn ?'I{1 e Your grievance has been received and wrtl be processea in accoroance wui.uu-r uivl ouY. Signature of Facility Grievance Coordinator R OFFICIAL USE Y EVANCE NU Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - inmate Copy Revised n.rpm Ir 9nnn Form DC-135A INMATE'S REQUE T TO STAFF MEMBER 'tiCC ' D. M'?`k ? ?:)'V C, "mmonwealth o nnsy vanla Department of Corrections INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more rom tl and intelli entl Y. 1. • (Nam'e`.r d,i Title of Offic j 2. Date: H ra-? 3. By: Pri ate Name a umbar) 4. Coun elor s Name - S. Unit Mann ame Inmate Signature 6. Work As ' nment 7. Housing Assignment 8. Subject: State our r uest c letel but briefly. Give details. 1 t' ? n L c )' C 1 ?,?. G 1 t`?7 fT, [[y t 7o DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name Date Print Sign Revised July 2000 L USE Pad. DCSD04 7 - t ,(?COMMONWEALTH OF PENNSYLVANIA >AN l DEPARTMENT OF CORRECTIONS P.O. BOX 598 NUM LL, PA 17001-0598 AMP HI uwrc I"o?cVn wl!`C y vwu+r um•e?, r vur .r.....r TO FACILITY GRIEVAVQE CpOORDIN T PR FACI D TE% FR M: Nt{1ATE NAME 8 UMBER) e _C1i? U of INMPT . N, WORK ASSIGNMENT: SIGNMENT. m; INSTRUCTIONS: Refer e Inma a grievance sys 2. and a e v nfiaff n to resel re this a#P R 4 inrlll is tF1?ldPnti} R t ' f ' Ri k h '' I ? e a I ake 3. I , gee I 4 Gtod A m e Air, cy "I'A. t z C- L} VV c ?C C -E? ?L?? °? '11-1 C C? 'r L? G L rv?,` c is?{t,? ceL??'C+?CKvi1 Corti C?[? c'+.? B. / ? k _I ? 7 ((ry\( [[} { I K-A (I .Il l-l?( C` rCl 1' l?' C, Your grievance has been received and will be processed in accordance with DC-ADM 8 _ Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised DC-804M \ /ate. V ( 7?. Cl-? ALTH OF PENNSYLVANIA Part 1 DEPARTMENT OF CORRECTIONS P.O. BOX 598 OFFICIAL INMATE GRIEVANCE CAMP HILL, PA 17001-0598 v- t P' Ii 11 > 1 11 DA FRAM: JI ATE NAM NUMB , I SJ&NA ?l1 of INMATE: U _ AASSIGNMENT: ORKK E 1 SIN SI _ nw INSTRUCTIONS: State year grievance in Bleep a er. ' 3 q?rmapTl ?a ?caKenTO resotue thlriiafte -Besure to include tie identity of staff d. .rP4mbers_y©u4have--Gaataote ? V / A n ?_ AV,J c_ / L y > , " a ?c? ?c \ SRC tv z s- . ? -fir "> ?tac Liu -a_ y •?, '"C - / 1 I1 V ? C_.?O,1LCt bpfoFe 'r,_iftl???5 ?-''- L \ K. Your grievance has been received and will be processed in accordance with DC ADM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy o...,.-crl Y'1% MONWEALTH OF PENNSYLVANIA FOR OFF USE ONLY _PARTMENT OF CORRECTIONS P.O. BOX 598 AMP HILL, PA 17001-0598 GRIEVANCE NUM =-?'??. \I ? ? FACIIITY' ?.q _- `( al . l . e FROM: (INMA'Y?E NAME & U ER) ? r S AT of INMATE: Yj 1 1 y-x _C", l i c °" WO KA IGNMENT: HOUSING /VTS)GNME N (: € _ - \ 1 INSTRUCTIONS: nn 4l1.L?... r1 C nr 1 O f 4h - --? 4 t fh D(' or . ? t P o P 2. ble manner 3_ e-toanslude-the-identity=of staff membgr???? have r?n4ar4P.+ A . i Pah I' lay uc 1 r 0, 2 \ B. / - s rx? ttiaQ th' - levance: € ?QC ` ?1 ?'. ?1 Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised w : DC-804-< _ '`.FOR OFFICIAL . Part 1 COMMONWEALTH OF PENNSYLVANIA .. ~ J'- ; DEPARTMENT OF CORRECTIONS -' •., 7 i ?' • fi .".>... + -`'-"""` ,." P.O. BOX 598,- ?. GRIEVANCE f- ` ?.^? a cr ' V 6 CAMP HILL, PA 17001-0598 .,OFFI CiAL --ItJMATt?G R1 AN F- T4°,FACtLli1'-G RIEVAN G 11N!AT? FACILITY: DATE: :7 r SC FROM: (INMATE NAME & NUMBER) < t t Z SIGN TURE of INMATE ( '+ t +; J -? WORK ASSIGNMENT: HOUSING ASSIGNM ENT- _ INSTRUCTIONS: 1--. Refer,to-tbe-0G=Ai3M^8e4-for°procedums`mrt7e^tnrnate graevva'nee-systeFn- 2:-.State yQ,gL_grievance in B A in a brief and and rg standahlP mapner. 3. 1 ist iraU3lock •Bar?yactionsgoe naay?iave takerLto resolve Yis roatte? Be sure to include tJ? j{Jt ptiYyofataf mefnber-s-ge t-4;eve-con•tarted _ A i tde a brde lean state ant o your grieuara e-•Additional-paper-f+narbeiise&Tnaximum-t -a f P"Ceiv =oa F_ , ,-?? ? •?.;? R? rp?c t t 1 ? , r , f r h 1 Y ar E 1<i t r >C ( '?L 777 r . f t - u , r, ' J B-istvaetions-tat?en a 1 r4[1 staff y u -J ave-eontacted, -before-mbraitting?,fhi"rievance-^ l a 777777 F 7 u! + S ". Your grievance has been received and will be processed in accordance with DC-ADM 804. ture of Facility Grievance Coordinator Date WHITE - F i iCoordinator Copy CANARY - File Copy .PINK -Action ur Cody GOLDENR - Inmate Copy Revised 804, (r-xRx T II COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001 =FICIAL INMATE GRIEVANCE E ): (Name & DOC No.) FACILITY :W, Alphonso ST-7263 SCI-Fayette ie following is a summary of my findings regarding your grievance: GRIEVANCE NO. REQUEST HOUSING LOCATION GRIEVANCE DATE J-13-1001 06-09-04 OMPLAINT: Mr. Pew is "complaining about inadequate psychiatric care" since his arrival on 12/18/04. le reports that Dr. Saavedra was stopping the medication because he refused to come to the cell door. 'INDING OF FACT: Mr. Pew has not taken his medication consistently on a regular basis. First he said ie wanted it and he later said he did not want it. Dr. Saavedra's response has been to gradually "taper )ack" medications and discontinue when he believes it is not needed. Such is the case with Mr. Pew. n ate/ psvch_>rist conversation can and does occur at the cell rather than in a Drivate_ Ice at the DECISION: Grievance denied, no merit. cc: Superintendent MechlinglFile DC-15 Inmate Print Name and Title of Grievance Officer Gary A. Gallucci, Ed.D SIGNATURE OF GRIEVANCE OFFICER ?s; tl, a-c2 DATE 06-21-2004 t v:DC-80at?.r.. Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY GRIEVANCE NUMBER FACT DAT ; C- cc 1 F OM- (I AT A & UM SIG U E f INMA E: ?z 7 } Y k W R ASSIGNMENT: HOU ING N[v1EJ: 1 1\'? INSTRUCTIONS: 1 0 2. our 3. 'mgmbep A. n ' i ?ik B-List actions to en an ?staffyou have cfonta-crtt d, before submitting this grievance. Your grievance has been received and will be processed in accoraance wirn vt,-ADiw ov4. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy n ... !--A D_ gpq 12 FOR OFFICIAL USE ONLY D^w 1 r MMONWEALTH OF PENNSYLVANIA ! G ?7 E l DEPARTMENT OF CORRECTIONS P.O. BOX 598 GRIEVANCE NUMBER CAMP HILL, PA 17001-0598 4 TO: FACILITYGRIEVANC - COORDINATr , F IL DACE FR : (I M NAME & NUM ?} ! SIG U INMATE\ WORfNMENT. HOUSING'ASS ENT INSTRUCTIONS: 1. a 3.r ' es, A. brie" , _Z- k C C- C.ZL- 'F?Y zk- ?L•1..1t/ ? V -.` Your grievance has been received and will be processea in accordance Wiui ul. --Muhl ovY. Signature of Facility Grievance Coordinator Date 4= WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Ro„iccrl c 6- t5 DC-804~-Z°-ir' r ` FOR OFFICIAL USE L Bart 1? OM ALT F PENNSYLVANIA )(C <DEPARTMENT OF CORRECTIONS P.O. BOX 598 VANCE NUMBER CAMP HILL, PA 17001-0598 T A I -- DATE' FROMA(IN T N ME & NUMBE k) SI rat R f IN WORK ASSIGN M . 1NME,: INSTRUCTIONS: rlcvanra c +c1 th inmate d f g ?r?S-faA ?f --rrBCe '-9 icrfer t9 thB B6 QfJ dable . List' Ri k B any nrt' zy may have taken to resolve this-mafter-Za-sure to inch the ide 3 . -A-Piovi bhe+7-i; le !1: nal a er m tu> `. x c . -r?-c Q - n Di +.? v i J n AJ k = =-' i i ?'lE 46, w? ti , -->XG) y -dA Ail CIE uz? Your grievance has been received and will be processed in accordance with Dc; ADM 804. Signature of Facility Grievance Coordinator Date 4) WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised '? ? • $??,°h ```?-wt's ??t 1?..? ?'- 1 DC-804 V?Part 1COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 r T - FACILITY: L4 FROt' : (INM TE AME & NUMBE 1 U E INMATE: J b KAS?GNMENT: WO` l USING,S GNM r 7 1 ?e i INSTRUCTIONS: 4 11511 •I ? , ??? ?, ?.''? ?.-R?-??...°?--2'`-' Cam-, '? 5 C^ k c Your grievance has been received and will be processed in accordance wim uL,-Auivi 604. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Rpvigpd \J ckj-? ?? 1.C-.1 its f / ti l-k t,-%- ?- ?\O I ?\ Kul 1. , . 4 I-C Its L-k Ap v? V--? C? _ 41-6 imp,c-?l?- f 9-d ? erg- c C r?CP cr _2t ILE S; i ter. ; r\12 G?,-) ,-?- n-? - ?NID czar ?,eC1? cv C ry-???c- u c ti ti*?c`. t fl, 07 ?Gt41%A_ _m - - DC-804 Part 1 a t COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 OFFICIAL USE NUMBER orrtaAL tlvmH] c vMIave l"? ' 9 F I T? - D 7 FR M: N E NAME & MB ) SI T R f INMATE: WO K SIGNMENT: HOUSIN M T. INSTRUCTIONS: It. 51!alle yed, I. 3. A. mc. at v a Q B. J Your grievance has been received and will oe processes in dccuiudncc Will, v - Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised gaom ?Jhe Desk oj: LINDA D. HARRIS. Deputy Superintendent for Centralized Services SCI-1OfFrWdE5BWRG ftta fry r ye r lz; ` - ?DG8044^=?-PENNSYLVAN "?'N 2 4 200410IPAR ME NT OF CORREC IONS IA P.O. BOX 598 -?- CAMP HILL, PA 17001-0598 ,/,RIEVANCE AI !MM ATE Y T(T FACf?IT? GRTC{tNFE COL2F1N r??1/_! DqE CILI]]'._.r ?j?( - M U SIGNATU z f INMATEA E FRO : (INMA EE NAME & NN IBBE,R?) t t6 (P `} o [[`e WORK ASSIGNMENT: 1 Y HOUSING SSIGNMdEN , ? } MID @ I 4 ?J INSTRUCTIONS: I -Refer-4o-the-3C-AIDM-&04-for-pr•-ocedLaes..ora-the.inmate-grievance-system -z-.°•5ti3T"'ye HtlYt?rievenee-irapBloGk,.AWiraahrief arad?udadersts?lldable m=r?nar _ 3.?-Lwst-iPr8loek-S-ara3?as,Boras.yy.„Il??,vlcaaa°to-resoivt?`tfi5ss°matter-8e„SU1:?to?inefude"the"i"d'e"'n itgrof^stafl raaernbcrs.yolJ.ba??a ror}artp?d?-_ e-used?anaxirraam4wwpager ddltiona4aper- mpy-b griev a nss A dear statemeaLo€-you f- A_P_mwdi.a-brief 4 __ __ t ? / ` 5--KrC.,°.k"?°l?E?.?r?t.(?.d?°Fc?Lti.se4?tiCr.?'tfi"?'?t?L?:`?S?,C'</4 ` ? w W , e tcsti?CG p.(r t? ?.,a fat (/ ?; v { ?E CGr??, EC J a G ??2?atE 0 LA %Lk Ct?? a - 6r !dE-`?f3tvtc9f' trot et " vcm l?f?0{"t1w (a? 4P At4tiJ 115 { .flf`i A"S -? t ? 6i LLk ( ih.Y E.s S, i?l G f, <?'' PRs r.y, ` SC{F nntt _ t-( 21 ? ?? `..F.:. h' `4.VCy V wc,? f•J 'f. tp,??at ,?,. !? Usl 2` +t ?' "dV r C e aE c.?Als ,, -('-,y C; t W A Nt . I '-, .) CC TC.- ! ..{ a 5"-'a ?y I P?C ""-"`•' S-Eq.ef ?l }' ftS L?•d?,.) t?" _"t?'1i'arlr. 4J S. Lz1`f-tit "4 A - - ' W -'S P C ' i 6 4'iG1 P" `r'i tuC,p f u?vF' ?/ ?frYS Fa 6 ?3 Cht in, ? ` > Crib- hC a,??, 4 44L l. GE.t.3 ?•t???:! F - ? ?? S? ?. ? V?-•,G,f ? L`.e ., y C fA _ • 2a ; s ?! ? ? , ./ wte t?.3"?-?FC...fi'Cm ..i- •r"eCi`E 'P'F; le-C C{(C(?r;C.or?' ?? A°.L7-F--` ?tr5l? N •C ? •. ,, . FP?!°wC?r'C"P'f-h.rc- ;:I ?F???. Arri ?*`rtv("C E:4 Rte.} /ha C P_ E-rccrb<l is '?r Cc?g c??}e ?C4 wog "ra a { F [ , ( kj t'"H.© ?? "'s. ati:'r?Y t{y IM1,EE s,?y f? fCL{?(w +'t aJ .`S S!('f Q .i ?sS {rre„ 4Arg r Cent Fc( ?`,,? ?» k ? fir r 5rr? c?J qn L OE rjr,,Av .se clrGoAx1 4-,d v rG3 ' ?v ?a -' 6/ [ j ^?6( / ( } r(1^tt Wn V2P.' k It ,1 r5 C? 1 B. List actions taken and staff you have contacted, before submitting this rievance. 1•' ?.lx-,-c 6 J , 'r Ft^E? x. lst?"i-GP??i^ h"YG?A/ E7 .' ' 1 fir' -Ls_ - CC t,.. -Ff f ? , 1 F- `+?, s-S-6. U'u '•r`?i G C1 E".'!'."..%L..7 TIRrG?,'-... k-'i.L.l,? 46""' -T--?--- r 4??qG 2r"F-_. } ^CX4 11 1 ha C'r <ata r`fc Fir. CCU{ GC . 1 l.<r?,1 ya ?1'•t-. -L.e ? `+'i. ?l. ??! l- C+ I?? P..`i I(YYf h ?'i S I 4 Your grievance has been received and will be processed in accordance with DC-ADM 804. / n 'M'fe ' * L - H.? Signa re of Facility Grievance Coordinator Cam'-(?Gti. ?.c Date ? X [J G -U?? zj WHITE -Facility Grievance Coordinator Copy CANARY - ile opy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised Part 1 4?C?, VG OMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 RIEVANCE F FFICIAL ONLY GRIEVANCE NUMB OFFICIAL INMATE G hIATr)p ? SCI . I ? tl DATE. 1? ' ' c FR M: (I NAME & NUMB R) MA U of INMAT ;- WOR AS IGNMENT: HOUSIN GNt E : INSTRUCTIONS: 2. 3. iirelribe+y-per?palE.('ontarr ? IL i tiS ?ca6+`TWv ril?L? ?CCM,' t4ct?lfi" ??°? ? A_ ?Az ?" IiCk4e,. C L L 'm?. n? rtN V1 f fY?f? L ?1 r -t 611 `r_ L•c.Csa t yew "??- r?-? l h? N1 t t `1INA IccE rte' .t?v taff you have contacted, before submitting this grievance. B. List actions taken and s ?( %t? n- c_ ?- V C?L Your grievance has been received and will be processed in accordance wan DC-ADM 804. Signature of Facility Grievance Coordinator Date F, WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised -4 Form DC-135A INMATE'S REQUEST TO STAFF MEMBER /Commonwealth of Pennsylvania Department of Corrections INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligeDgy. To: (Name arid! Titl of icer `J 2. Date: 3. By (P -lInma a Name an Ik N ber) ? unselor-! Name -A 6? - x 5. Unit Manager's Nam /g 7 Si nature J -e 6. W As ignment? 7. Housing Assiqnmen 8. Subject: State our request co but briefly. Oiv% details. a Y\ - e ? - rl c- i- ? it m o To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name ? Date Prim Sign CC,_ Revised July 2000 0 4 Form DC-135A INMATE'S REQUEST TO STAFF MEMBER Commonwealth of Pennsylvania Department of Corrections INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligentl 1. tw.,(Name and Tie of Officer 2. Date: 3. By: Pnn ate ame u . )4. rounss?or`s Name _ 5. Unit Man e ' I mate Signature Q ? r, Q-? 6, ork sign enV 7. Housin signm 1 I 8. Subject: State o uest completely but br Give details. c,, -) s3 pnS ora S ans 'n . . WIN I" W To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name Date Print ?-' sign'` Revised July 2000 b L ? k ? L )l Staff Member Name 1 `oW?V / Date OC ?/?1 ?Pri?nt???y/?? Sign Revised July 2000 Y \ V 6 j \ ,? 11 I f f Form DC-135A INMATE'S REQUEST TO STAFF MEMBER Commonwealth of Pennsylvanp,, r J Department of Corrections t,Ak?/?t"I? INSTRUCTIONS l? Complete items number 1-8. If you follow in I preparing your request, it can be res ed promptly and intelli entl . 1. (Name and T' a of O Ice) 2. Date: 3. By: rin I a Name nd um er) 4. Counselors Name 5. Unit Managers N I' to SI nature ?- - 6. W'rkAssignme t 7.7Housin ssignment 8. Subject: State our re u t coQ4de but bri,?fl . "Z details. D L AI i y: I J f _ 1 To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? ?1 ° :-DC-804 i nvorIwI nuAwTCno1cvwraro DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 R OFFICIAL NLY VANCE N ER FACILITY: DATE: r `f _- FROM: NMAT E & NUMB R r of INMATE: WORKAS GGNMENT: HOU?SIN SI NME 1 NT. INSTRUCTIONS: 1 m. LVM'eVanr in R o k n 'n •, h f ri r,aor?foe.Vol+Idz,on ncr 3 have taken W-Lea0ble -this matt pr RP cure to ind di Le-. ? sa A. b-a?.?? tr?C,;t7€?o vas-c a - 0 - .?--?- A,- VN,\ C \JT Q- 'k-j, ? lACTL? . } -s?? S Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date I° WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA / DEPARTMENT OF CORRECTIONS ,? `?{? P.O. BOX 598 "Gl? CAMP HILL, PA 17001-0598 r1FFICIAL INMATE T F t7a ? 1'? ? c_ ??vt j FR M: IN E NAME & NU ) TU E INMATE: WO ASSIGNMENT: USI Ig M T INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. " A- pFe tC-C?l BTU ?4 a1_ ? ' GA c?csti L? ?= S 1?Z?C' (??[1 ?5 S3 ° _t?lC e C ,ts . r Ole ?'L-? n`? c'? L l M1 l t o ?j p -- E Y' Ct -N ' . 1C / tom r? ('` ? >v tm. T-A- C, B. Is ac I ns a you nave con ore itting this grievance. t St d ' '?vC C U Q>--r Z uk'D C t t k c? Your grievance has been received and will be processed in accordance with DG-ADM 804. Signature of Facility Grievance Coordinator Date 7 yE WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised DC 804 r f L A ?rOR OFFICIAL USE Part 1 COMMONWEALTH OF PENNSYI( , DEPARTMENT OF CORRECTIO S ^±,, } i P.O. BOX 598 C ?k?><`{ ?( "•,J CAMP HILL, PA 17001-05 Rill E? NCE NUM 98T OFFICIAL INMATE GRIE rIMNCE-- TO F„A'C. W _ 0f 'DINA?*C Ff?CILITY: =dD DATEj FROM: (INM @ DAME 8 NUMBER) ? ? I ? ` SIGNATIJ Eiof INNIATE`< - ' , ? ? ? r ?? • ! "rl'?. ci -rte \ J [-l' ? ?? ? Y `i ?`?.???? c, F f ? `C">??. 1 ? 7 `?` m } `v ? ?°r. F1+. A+v..L?a. WORKASSIGIJMENT: HOUSIN_GA'SSIGNMENT: INSTRUCTI NS:-,--__-.- r de. , , sr ' rtale taste; -stain d n dab er. ly:bln ©... Fi a e Ie dIffle mO `i?_staf:. 3 1..ti tasf?s+ur?guieva?e ? ?i on ,? a}rEr hay.-beuseti? 'm a ?TirtiYitiwo?? a ges_ A Ps c ._v ?d_ ?_a-br?ef.?clect?statt _ [s g ?+ w?? { `/? pp .43 p ] l _ n ?\.. _ L "1 ?.? t '.`TJ ? t 4r &`J????+,.. FL. •Z i?? ('-'F^{'v:,' ?.L,_. `' r?, t} ^.. i `fi ? V V ?! • `"4_. ? (?' g( ? ? Y j, _ tt },, ,(? ?j Q ?•,.? EtE ( 77 71 , (g V`•R?t t "` ? ?. -? . ?'?_? .l.?????'d y`1Gr??Q'C.?? a ??iFY V??r. ??` .- 4?1 •?1``?e ?? ,? ?. r ? ..\?Y"--?.' l IA- a tEAZ-±: Al. ZiTi?`dai'?E=COA?SC-'I0d{?+I7EfOr?E-`5Bt7xJf n? S'J•e(;1f?a3L1Cs,P,?,_(_ i\v B. ?-i?/?T3I'I \ -: r ? ^ ` 1-?'r'^C;L .?`C ?C.-'?J ??+ \ ' C'J ??"+'"+? V ? ?? ? ? ? ?n 4t?? ??D?:° \.. ?J`?- ?--?-_ ?"?'.t.. '...?: ? i?.;?= J V \ t__?.'?•••_ L C_7 tC? K-?, t ` `"1, t t-J•'.'1 > > ? ...'"ti -?. ?^._l V(j I"?v `'?- r, ? .I '? t?lf) ': i ?V` E.:L , C ?=?i. l?•J ?{ -4? 1.-1"'F- E. ?? " t'C_?".. ? !..__ f?1 Ck, 5k? 1 00` r _ t -??. ?.A_??'?% ! F'?e^.=? r4'• '.?f-.bv"..?. _._ ? ? F"C:? I ? r E'? ? `, i \ `l =? -? T- 1?1---_t-•. ? .: . ?.,--ai_.. a Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PI. 'K -Action Return Copy GOLDENROD - InmateCopy Revised DC-804 Part t COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS II ''P.O. BOX 598 CAMP HILL, PA 17001-0598 F ICIAL USE O IEVANCE NUMBER V r r IldMl uvnwF. v.w+....? T F I DATE: (. L FR M: (I AME & NU ) SIG N E_ WOR ASS_IGNIjQENT: GF? G INSTRUCTIONS: 1 ' 2. _ e. [mirbeis A. P Al All- e ?. -? a is! "wt n s B. - 's-grva C ?` r y? 1 I vC` ?* t .. ?r? o it ' _ ti f ?Jt Your gri ante has been received and will be processed in accordance w,crr Vl -mum ouv. - Signature of Facility Grievance Coordinator Date Will Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 yq,?, !.:e CAMP HILL, PA 17001-0598 OFFICIAL INMATE T F lL FROM: (INMFXE NAME & NUMjkER) SI UR Eft if IN WORK INSTRUCTI 6 (?- w to 4' t- V 1 v CT -fit 6?, t R OFFICIAL USE O G ANCE NUMBE Zil ? .T Y ?P. i 4 L??aCG?t? ?" VVtii?cr?_i ???? ???q Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised DC 804 Part 1 F COMMONWEALTH OF PENNSY Fkc ived ODD ?ICIAL US ,,ONLY (/ / DEPARTMENT OF CORREC O 200 ( P.O. BOX 598 l \. .k.?`'•^'"?.tF tl- '°v?. CAMP HILL, PA 17001-05 - IEVANCE NUM B OFFICIAL INMATES - L T9: FACILITY ,r FCIpLhTY;,,_[____ DATE: t, FR (I NAME 8 NUt } tvl SI ATU?2EErof INMATE: I yy WORKASSIGNMENT: HOUSING??SSSIGNMENT(:-', -7 ` 1 t5 INSTRUCTIONS: 1 .Rs€ef - . a rtac ;Hr?s~=tfaair?mata?si>i`vaxtce-sy?tarn?.. 2R--Sta ,?; rid-i?sadarsiarxdabi?-r?a&??:te?,. 3.-L-?st in $l001?8-atayasEioa?yo0?a?lak-enft?',r?sZa1ve:this-aaaatter?.$e=saTe:.tv?cltl>Je:tttl`?iiecati T :tiff _.memf+.ers?+m?aef?ir ' A.-Provir?sr?r'-??a?caatt?eta?^.egcie?dt??. ?"?ftA:d"d tTonaT=pap>:st-?aaq?be°aced-rrla?ctrlfl[i1??!NO images. / t e " em Sim r - : i? ,?, ?"''?"±J 5, 17 = 1 1 ? A °'c-- ? 1 . ' 5. ,r v ?" 77 7 7 (2 C? B. as rr an a z eor?ta ted'b`efarecsubmi tn lj? 3tn'Rrievaance> D J ?`E `y ?- 5 if' Your grievance has been rreceived and will be process d--h ?accordance With DCr-ADM 804. '? }.•`- . ? ? l i ? Imo-'' ?? '"1 ?' ?--? Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised DC-804 Part 1 s i -4 a qia IZT- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 R OFFICIAL U LY GRIEVANCE ER ALM E F tILITY: D FR M: IN fJE NAME & BER) SI o INMATE: \ f, WOR AS GNMENT: HOUSING SS MENT.? y?Ij INSTRUCTIONS: stem 1 2. -State-yebIP-087SIT'd III 3 1 f W _ h fal<an to s61 [e thi?aaatler=B?suf to i°? -- m?#iave=serwtaGted? z?21_; n SC_ i-L CS ?V A - h ?. t? r Lirl.v L ) .? - _ an sta ou ave contacted, be ore submitting this - c CCIL,R ?iC???Ci tee P ems; lL, ?? c , S Mecl?C zt- d e ?, Dom` - 5??-e CAiI c scE,cc-2 OhA Your grievance has been received ana win oe proce55eu ill cu.uiu-- .11,,, ,-- . •--••• -_ •. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised 4 -4 --ate ui,-ow Part 1 COMMONWEALTH OF PENNSYLVANIA FO ICIA E ONLY DEPARTMENT OF CORRECTIONS P O O . . B v X 598 GRIEVANCE NUMBE CAMP HILL, PA 17001-0598 R _ r EQ ITY: CJ DATE: ?? FR : (I E NAME & N R} 1 SIGN R f I MATE: n WORKASSIGNhME?NT: ?IV HOUSINGASSI MENT: ? INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. 1V. 7 C Ls. _? 1 IlIc B. List actions taken and staff you ave contact befpre subbmittiinn this > PL ?• a 11- --ir r-l- allu will ue processea in accordance wan DG-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy D ovcorl Staff Member Name Print Sign Date Revised July 2000 F. sg ?zt t?.R C-.?-1 -4 C)I- VV , 1 ? ? L?---?-?Z, ? ?T "C Vim, ?-- ?j ---?.?•t p?h-- ? ??^.?,. Sam xQ-,&, ? J, Cv- "' ' YLVpNtA "? PENNS i Of CORRECTVONS 7G ? 7 ??nC 5c COMMONWEALY L OEPARTME 0 BOX 598 t P. PA 17 001-0 598 HSLL, --- ? ('Y ? CAMP of INSTRUCTIONS'. ? Y- -?y?.rt? tt?. ?Llu /?,a.1 we T-cv? tbs?t ?Aj 3 J t?Vw f? S _ ;-ye qty L C1? 'U ?Ma g;vlaas 4F3' 4 i i??-,";E adz iws ; 3 -°CV" l? t..:?-r42`i' ? •Y.? ? ` ?h,?,?. e l i?y n CS IJl$ C '? v`j?za h ?'./4}qG? ?v -4t? DI L-On ?' _ a et c V?'`z i? "3 `AJ, O s y °k s? tC ! nos ?cf?"L{r- g' 4\1 - ? ? ? d to accordance and wilt be grocesse _"'! as been received pate Your grievance Coor copy GOLDENROD Inmate CoF Grievance Action Return of Fac?llty COPY PINK- Slgnature .._c _ Facility Grievance Coordinator copy CANAR Y - File , Part 1 CO :?. rEALTH OF PENN IA DEPARTMENT OF CORRECTIONS ?J P.O. BOX 598 CAMP HILL, PA 170 001-0598 INM OFFICIAL 3 OR OFFICIAL USE 0 VTO: FA 1 I D TE: FR : (I TE NAME & N ER) ,7 S TU o INMATE: W RK SSIGNMENT: S MEn n \A I INSTRUCTIONS: 1 2. 1 - 3-1 6,t I VIE 8;r I'm A, Jis - 4L- Cam ??? €1 C --(-77 h2 ' 11, CIC c c NV- .vw? - B. List actions taken and staff you have contacted, before submitting this P Hj__j, C 4?--l l ??c E? C.? Vco C) lz!t? Li, C C v> Cat Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised FOROFFIC IAL USE ONLY Part 1 COMMONWEALTH OF PENNSYLVANIA L DEPARTMENT OF CORRECTIONS P.O. BOX 598 CE CAMP HILL, PA 1 7 001-0 59 8 NUMBER OFFICIAL INMATE (Ta. C?V (4? ?(j rY\( Cs? TO: FACiLIT RIE ANCE COOK IN TOR - E FACILITY: •? DATE: S P ?R . F OM: (I 'MATE NA & NUM ,,tt ER) 01 ?1 1 ? SI AT of I NM T . N N ? 1 J 1 V? ? _ ? Y L W R ASSIGNMENT: ?1?5 HOUSI G S IGJq MEN ITII INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. C>?uhc?k 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you m y have taken to reso ve th s matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance Additional paper may be used, maximum two pages. -?-? -?vh 1 bF C K P ?3 i C .? ?kJ?1?s - a ?KCL' z e' CIT?"?..AJ???.a_ AfI?V G-?v?cc a wv:."`?-C,? L 4 ` 2- E C?ti? 1.t A { (rte AAc, .. C ??J hh. lC`= (`mac v ( lr. . - ,? S ? ] V\A o, ? ?? ? t' ?rt? ????>s?' C?C?A ,?c c?? cab `\, ? -?? ?.•-??_? ?t:.?-e -Z:cL6 --s- ICA Ay- + ' -. Ta' A .-c?_? ..p y 1' 1 ?W ".1"?t'`-t. ?.L?:?2-'z= 47 B. List actions taken and staff you have contacted, before submitting this grievance.-.gg 4 c's l ?I Cam- (_&el?ll C_6? , Y a N C 6z_ 1_ _ _ 1 ?'? ??-.?.._.+?? vti?? y.rti0 ?r..? ("('u. ? ?y ?_ -? ??• C ', 11-?.rJvt; ? _ . Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE- Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Rcvimri C. k I.-_ DC-804 Part 1 n0 !r! A! MORNAY= GR!EVANCE Cs?) FOR OFFICIAL USE O LY GRIEVANCE NUMBER T .p,C1Ll DATE, M X (INMAT NA 9 WU ) „ F T E" f INS MAT SI _ WORKASSIGNMEN : USINGA SIGNMEN y \ INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may hav taken to resolve this matter. Be sure to include the identity of staff members you have contacted. (c C - , A. Provide a brief, clear statement of yourgrieuamoe Additional, paper may be used, maximum two pages. ? ? `_J?'?-1V- l1. C ? ? ?V Yl 'T!? ` f?! V•?a V ?Q?C' `4Y ? ?1(J ?"??_e tc { ? 1 ?_v &a° G? C; PL e?? bb cue c_r. ? ?cc•a i?,ti? ????C ? ? , e? 7 VN-K ?Sa..(- \? L!VV? ? P G\V!'IML?l? V vi`? t=????t i?t ?P? ? .. ?( .1 tL1YV A+O -. / , ?t i ? v ( .+r c(?• V FLJ?? B. List actions taken and staff you have contacted, before submitting this grievance.. ?t'--CT??? ?-1-??L?c)`? ? ??, ??? ?t,C?i ll? PG-??-f .t ? 5?.?vS,? (( ?? /? r ? ?y LtI` Sh L.+E c- IIrNaQr Your grievance has been received and will be processed in accordance with UO-ADM two. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised N Form DC-13(5A INMATEtS-R QUEST TO STAFF MEMBER ComD ?par?me monwe Ith of Pennsylvania t of Correcti INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligently. 1. To: (Name and of O icer 2. Date: 3. t nry rate Name an u ber) 4. or's Name 5. Unit('Ma a Inmate signature 6. Wor ign ant/ 7. H Assignment 8. Sub'ect: State our request com letel ut briefly. Give details. e> 3 c?e N L' ' tom.. _ 1 C> =? I I J - U , " I -- i i I I I i I To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name ! Print Revised July 2000 Date Sign I ! Form DC-135A Co onwealth of Pen ylvania apartment of Corrections INMATE'S REQUEST TO STAFF MEMBER INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more rom U and intelligently. 1. o: (Na nd Title of Officer) C? 2. Date: L C L- 3. By. Print inmate Name 2'16`3 -Numbers CounselQPs Name 5. nit Manager's' %fnmatesi nature 6. Wor Assignm 7. Housing Assignment B. Subject: State ou r ' uest completel y b iefl . Give details. - t e-j c, a r ,.,.?_ i..+J' f.?fi,..KG i. ?!?"C.v'J ..,7//?.. /++C ??rr• l is Jar !,^ a d ? cc. / ?. e- ce dx a Q/ C'.-•..s i o!F, I To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name 01,61 I Piint Date Sign d'` s v Revised July 2000 a ? ??r , V A e-c-k -ILA ) () Form DC-135A INMATE'S REQUEST TO STAFF MEMBER ealth of Pennsylvania ommon Corrections ment of INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligently. 1.? To: Name an Title/of Officer) Date: c? _ C? 3. By. (Print (nm'6te NameAnd u er) oun lor'sJJa?me r 5. Unit Manager's \ Inmate signature f 6. Wor? Assign 8. Subject: State our request comp letely but briefly. Give details. -C c' ' I Lk") - To DC-14 CAR only ? To DC-14 CAR and DC-15 IRS ? Staff Member Name Date 7 U Revised July 2000 z}???04 l ??? Part 1 4 4 -w-, b s a nc1:1c1A1 INMATE r_P1PVANCF Your grievance has been received and will be processed in accordance with DC-ADM 804. CO M0 H OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 gz`(C Aq U NLY GRIEVANCE NUMBER TO: FACILIT FACILITY E: F M: (INM E NAME & NUMB p-M ) h \-' 1 U INMATE: WORK SSIGNMENT: HHOOUUSINGA I ME T: V INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may hav taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of you Additional aper may be used, maximum two pages. ce IL b ?? c. 4_G7 Fi>-> w e ?G c try 7 =7 E 5M \? L cj C ?' C c 2?' C 77, x- u ?2L C ?t\ , A C'C i cA C 2- - i rte- C_'? L J? j 16( L CI ; LTi ( c 1?t r . ?Ca?j L?e? C' r7y- EC(CO a K.?L ??F-t P_ C B. List actions tpken and staff you have cont e e ore submit m is gnevancqI. ?-Dc'1c?? G z f?C? ? Cl; , ? _ CCU ?,I?C C 777- C? vti c T? , - J? .r j Cr L'1? 1?L C l S v ( r / ? Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS SCI-FAYETTE August 05, 2004 SUBJECT: Rejected Grievance Appeal # 85653 TO: PEW, Alfonso BT-7263 J-B-1001 tik FROM: Neal K. Mechling Superintendent This correspondence is in regard to Rejected Grievance Appeal # 85653. This grievance was rejected and returned to you because you have failed to comply with the provision(s) of the DC-ADM 804, Inmate Grievance System. Grievances based upon different issues shall be presented separately. In the first part of the grievance you _-\ address how you are unsatisfied A & Dr.'s condurl' II at the cell door The second issue you raise is tha o Wive that ou are no receiwn adequate ? tre ent for our saa is n e. The su tec s are not related to eac o er and shoul be Dresente separately. ADDeal is denied. NKM:jts CC: Ms. Scire Inmate DC-15 TO- art 1 OFFICIAI INMATE GRIEVANCE ?or?.", ? ? a ? Pc L >c COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY GRIEVANCE NUMBER TOTYGRIEXVQNCECO?ORDINATOR , F IT ?- I-7- I .S I DAT 01 FR : (I ATE NAME MB SIG R of IIN M A T WOR ASSIGNMENT: HOUSINGA SI NME`NT: INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Providd brief, clear statem?an, t?f y ur AdditiKaper may be us dxlm o pag s. v e' ? ' - r t1 .cD- ?N El ' - ?? ?-? o e ?.? Al as e G Ct `? ?- t r ts, C\ staff you have contacted, before submitting this grievance B. Li t actions taken an d .----v-- s ( / ? .-___ Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Co, Revised Part t?y RD`S COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS 7 r 4` m P.O. BOX 598 CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY GRIEVANCE NUMBER TO-FACILITY C= ,, FBCI ITY.? DAT : ty TE NAME & BER) FR M: (IN SIGNATURE of N E: ( ( WORKASSIGNMENT: HOUSINGASS ENT' j "ED ? I INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. List in Block B any actions you may have taken to resolve this matter. a sure to include the identity of staff 3 . members you have contacted. A. Provide a brief, clear statement of yourW ee. Additional paper may be used, maximum two pages. , c? n C G 7,77. r C B. List `actions taken and staff you have contacted, before submitting this grievance. `; l P 1 lFc_'?'S tailf 1 ? C: LI C . f C Jt n.. z Your grievance has been received and will be processed in accordance wan uL,-AUivl ou4. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised n..?..... ti.,. Onnn Part 1 ?J C COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 OFFICIAL INMATE} CAMP HILL, PA 17001-0598 OR OFFICIAL USE 0 G CE NU T LITYGRIEVAN COORDIN FR M: (INM E NAME 8 V R) Sl(?CTU E INMATE: J?` WORK ASSIGNMENT. HOUSII qAS ME T: INSTRUCTIONS: 2. 3. a the ide of staff A. Provide a brief, clear statement of yours A itional pa er may be used, maximum two pages. 47 GC-, t `? " ?(+ L V - ? B. List ac a en an s a you nave contacted, before submitting this grievance. -? T77_1 A. S, Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD -Inmate Copy Revised December 2000 Le `p Lii <C;+: 1???C7Cl CcC? -?, (-C, OvA ` c Cf=?? ,,?:CC `Ch CC??%1 C??s r?-t- J ?CCc?' CCC C A-\ C CCK-b { ,C 4c sC- C ?ti<cs ??,' E- U'N d C r-\ Li Form DC-135A Commonwealth of Pennsylvania Department of Corrections INMATE'S REQUEST TO STAFF MEMBER INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly intelli entl . 1, To: (N me and Tljtl?-?Dfficer) 2. Date: 3. B nt I a Name an ber} A, ou elor s Name 6. ?!k Assign rA 7. Housing Assignment ?( l 8. Subject: St to our re u st comoletelv Wt briefly. Give details. Y 4- ? C-- \ U Vv -A' V ,-P k C-. . _ V ) - ?,, - - hA c c 1VS 91; N ads, s, .. , a , FDA ., Al r fV a n 2 s ? t : .? n w c9>= P 5IRS 0 Staff Member Name uS / Date Q? Print Sin Ck- Revised July 2DD0 DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA DEPAR ENT OF CORRECTIONS P.O. BOX 598 A-L ? MM HILL, PA 17001-0598 OR OFFICIAL USE NCE NUMBER OFFI I FACILIT J F D FR : (l E NAME & M R) X12 S U of INMAT W RKA SI NMENT: _ H USINGA GN ENT: 7 11' > INSTRUCTIONS: 1 b. Id 9 2. 3. I= A. Provide a brief, clear statement of yo Ad itional paper ay be used, maximum two pages. B. List actions taken and staff you have contacted, before submitting this-4 . L Your grievance has been received and will be processed in accordance with DC-HUM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -inmate Copy Revised L LE_ DC-804 Part 1 '. r COMMONWEALTH OF PENNSYLVANIA - ' - FOR OFFICIAL USE ONLY DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL. PA 17001-054n GRIEVANCE NUMBER`- iv # 9sfNA FACILITY: DATE Y ' ..} `.77 FROM: (INMATE NAME & NUMBER) SIGNATURE of INMATE: WORK ASSIGNMENT: HOUSINGASSIONMENT: INSTRUCTIONS: 1-Refe'r te-#ri?bC Af3Nt8Q?".'?ni:Pr ,u3'ii?afe?grievarace;systern. 2..State- yaue?taDCa tralt?ak,A irtbrierad=ttraderstaradabte tnar?ner 3. .List`tf3=?lafd+d-a'?iroR'?cvDaa?aaf0mtaker?.fh?rtfAdW :rd'nio?:rai?tMa,?.#Z-a?c.,?,w?tra-:irt..Liarka,rhs:ilc.,k f ?.;s-br?R membecf Nreveoidfa'cted iffyou have contacted, before su Your grievance has been received and will be ordance with DC-ADM 804 Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised n,. •....... ?.... nnnn >C,1? t b i l ? ?1 DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY '-- DEPARTMENT OF CORRECTIONS -- P.O. BOX 598 i? ' '-- CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER -`---- OFFICIXL TO;.FACILITY<13,Q&.INAT,QR FACILITY: DATE: FROM: (INMATE NAME & NUMBER) SIGNATURE of INMATE: WORK ASSIGNMENT: HOUSING ASSIGNMENT: INSTRUCTIONS: 1 Refer-to the 00 A'DMI•B444bl" procedures?:ci thL irePtt ter e?q system. 2. State your grievartcaairt_&Ioel??lan.a bnefaradunderstaradab1e marFner: 3. Listin Block B any aettons you m ?'ha`v" fakenT eso'Tbe this matter.' Be•sure,to include the^id2ntity of staff .- m em bars -you-la ave'-ni3ritacted:- A Provide a brief;, clear statement of your grievance 6.Additional paper may be used, maximum two pages. r B. List actions taken and staff you have contacted, before submitting this grievance. ' ------------- --- - ---- Tour ynevance nas peen received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised n_,.,..... ?.,.. onnn -04 "SA c _c S DAVF? Y a ?? CQ) DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 ?,_&CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY _S OFFICIAL LI F I T : AyyTE N N ATE & MEER) t(tFM: TU E of INMAT? ASSIGNMENT: WPR? NO W HOUSING SIG ME T: q INSTRUCTIONS: 1 RAW . 2. mop I' waft 6-1irl A. Provid a brief, clear statement of yoou Additional paper may used, maximum two pages. c. c ca,C . 'EC vac. T--?ic> d c? C . 61 'j CA B. List actions taken and staffyo a lcontacted, before submi in IN ?`4-" Your grievance has been received and will be processed in accordance with tj.-rwrvt ou4. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised DC-804`;?c t Part 1 ?Jr??'rT `? n. wvuww wrc?SC- (F, ck 1? I- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 R OFFICIA ONLY GRIEVANCE MBER TO: FACILITY GRIEVANCE COORDINAT FACT ITY; DATE: FR M: (I NA E MBEg? r> S U E f I AT ; gkv_r? F2 WO KAS? IGN? T: HOUSIN?A I M?T: \L? (?, , INSTRUCTIONS: m . 1 2 _ 3. A. Provide a rief, clear statement of young Additional paper m{a/y/b_eused, m` ximurn two pages. I ?i {( Qt vpz ? C _ _ G?C?QtS L__... ? \GC;_ 'r1?C??C? l.U"-?1?.'???r +ltl ?viS????L.U? ??Z't?-C b F-??.> L 1 4 tea' ? ) ?a*A. S k 1 . t ? G C _ 77_t s' Le-Q- -'-fit-??t =c hig,gciooa"o C S. List actions taken and staff you have contacted, fore submitting t ? 2 L el AI_Q L t hcA 3 lp?C?'3 Cjz-' Ttj Q? b,ZS e? ? 1 ( ? gE;?C ? C7 M - _ ?IkvtL l c ? e t v , ?c t o t AAKj Q L C- c. Your grievance has een received and will be processed in accordance with DC-ADM 804. ? Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - Fife Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised n..,..,...tio. onnn r DC-804 - FOR OFFICIAL USE ONLY Part 1 COMMONWEALTH OF PENRPILVANIA i C DEPARTMEENTOF,CORRECTIONS OFFICIAL INMATE G H.O. PA 70 1 GRIEVA NCF-NUMBER ' CAMP j , PA 17001-0598 GRIEVANCE TO- FACILITY G)RIEVANCE COORDINATOR -7k FACILITY: - DATE % i I t" - f FROM:'(I{yMATE NAME & NUMBER) SIGNATURE'of INMATE:] ' F t? '? V?ORKASSIGNMENT HO USINGASSIGNMENT: *STRLI(7,TIONS:a` 1 Refer to the It-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. e na N > rr ?t 3 h I _- t r° • n Y 1.. t _ B. is actions taken ffaa s a you have contacted, before submi Ing this grievance. _ v \ Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised n.,Pmhpr 9nnn DC-804 COMMONWEALTH OF PENNSYLVANIA Part 2 DEPARTMENT OF CORRECTIONS P. 0. BOX 598 CAMP HILL, PA 17001 OFFICIAL INMATE GRIEVANCE INITIAL REVIEW RESPONSE GRIEVANCE NO. 96587 TO: (Inmate Name & DC No.) FACILITY HOUSING LOCATION GRIEVANCE DATE Alfonso Pew BT-7263 SCI-FAYETTE L Block 9/16/04 The following is a summary of my findings regarding your grievance: COMPLAINT: The grievant states that the inmate has medications that are being crushed. FINDING OF FACT: 1. DOC policy 13.2.1 Access to Health Care Section 12 Pharmacy Guidelines is followed at SCI-Fayette, for the disnPnsinrn of medications. 2. There is no violation of policy. Nurses are permitted to pre-pack medications,. --------------- Conclusion: no merit. DECISION: Grievance denied. cc: Superintendent '"'? Z d3S Deputies VIZ DC-15 (Records) Q3N3?3? Grievance Coordinator File Print Name and Title of Grievance Officer I SIGNATUREE ?VANCE OFFICER I DATE R. Tretinik, R.N., Corrections ?J? k _ 1? ?,J? "? I 9/24/04 Health Care Administrator ? Form DC-135A INMATE'S REQUEST TO STAFF MEMBER 3. By: 6. ne and itle of fficer) ¢c' t mate N m and N n Inmate Signature sign Vent KR--_ State vour request coml r Commonwealth of Pennsylvania Department of Corrections INSTRUCTIONS Complete items number 1-8. If you follow instructions in preparing your request, it can be responded to more promptly and intelligently. 2. Date ????-GH 4. Counselor's Name To DC-14 CAR onlv O 1 To DC-14 CAR and DC-15 IRS ? J Staff Member Name Print Date Sign Revised July 2000 DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 ?R FF SF,?D LY GRIEVANCE NUMBER urri.iAL Inmmi c un.?..+....? T Cl TY G V C COO DIN I DATE: FRO : (IN AME & NU ) T E MATE: WO K SIGNME HOUSINGAS NNMEN?T. INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have/teken to reso ve this matter. Be sure to include the identity of staff members you have contacted. I A. Provide a brief, clear statement of your9? 11e11), Addi' al paper may be used, ma, mum two pages. CZ VV B. List actions taken and staff you have contacted, before submitting this nee. ; ?7L I GQ Sh Your grievance has been received and will be processed in accordance wim uc-Hum 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised UC:-iSU4 _-0WIMMSE Part 1 COMMONWEALTH OF PENNSYLVANIA a DEPARTMENT OF CORRECTIONS € f? `?`$ P.O. BOX 598 CAMP HILL PA 17001 0598 , - TO`? DIN !1 FACILITY: (A rN FR M: (I M1 ATE NAME & N ER) > t C, SIG TtJ of INMATE: ( j WORK ASSIGNMENT: HOUSIN. > GNMENT: ° INSTRUCTIONS: L-7. ; rC r` -?[( ; -r KNOW A g "Z w ET - J< 1.7?. ^ 'i ?. L ( ` i 3c 'y t - `..>.`? v r ? i ' ? rJ _ Y r #1, F v / ? r C> ct ?r t ' _C 1 rs-c1l_. Ft Rxrt> ?LC4? f Qc' ?? ('?a ?c x v t x d? ' J C\? e. 1 1 } l ???? V3\? `` " 4 ?'- ? - 1- ? • C -' ? ' ..- . ^,. .. -+ v . ... V _ ? i . :? . ? I1f ?J .. '?'V./\i - ? - \ O ?_ c ?.?,_ ? C? ,C kJ?a YES k-C?t. k,;t ? ?. ' ?? C ?? a -l r? ?? < i r ? F 0 -4, NC- 77 =k?a c-L ?'-cL r C (Ct . =>t? -` tC e:lc+ `{h l}j '\` it ` ; -1) 'III NEI t `? '.ti n "tea -t' /I ti` p',`- f ' Signattflr" '?A 1, ° A IY ,.., } f ,t . Date \ ! WHITE - Facility; i ', d„a rdJi U!p Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised ?` r^? •°•, ^ - yp? }= t Form DC-135A INMATE'S REQUEST TO STAFF MEMBER ` Commonwealth of Pennsylvania Department of Corrections > (1Q INSTRUCTIONS pL? Complete items number 1-8. If you follow i st tij in preparing your request, it can be respot &/e promptly and intelligently. 1. T Name and e of O er 12 ' 2. Dater ?44 3. By_ (Pr'nt I aterName n umber _ C q. C uns?--lor's Name 5. U rt nag e "Inmate Signature 6. W rk A?si nmqrtt, _ 7. Haus' As ' n it n 8. Sub'ect: State our re uest co lete l but briefly. Give details. C 1 iC 21 Cv ANA V ? 1 1 ? y J n u r. ', ard.t_ nI .jkl '?'?: r'9L+s#,{u 6 '-n E 9 .'1,F2as #A U RI To C-1 AR onl ED o DC-1 CAR and DC-15 IRS ? r v Staff Member Name L? Print Sign Date 4W-?? Revised July 2000 ?, ?, ??W", , l ? DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA FOR DEPARTMENT OF CORRECTIONS P O: BOX'598 . GRI CAP HILL, PA 17001"-0598 OFFICIAL INMATF GRIFVANCF ,._.._._.-..,...."...._.._._-„__._,.._:..__.__.. -_. DATE INMATE: :IAL USE ONLY tCENUMBER r INSTRiJCTIONS , 1 Refer to the DC-ADM 804Ffor procedures on the inmate grievance system`.` " 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. +*, ytnti+u`rsns,• ? ?wmi M`"? .4? ` :-? " C 4??_ ? [`..4 1 ?..wr h ?+. , :t_ i.. _1 ?» ., t JtY ' t r di ,. i - . n.a F- K. h f - k •?.. ?_ ? 5r._ '... ? ? -. ..? l v«? .. y r l i t 1 Your grievance has been received and will be processed in accordance with DC-ADM 804. 0 Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD - Inmate Copy Revised ne?o.,,tio? gnnn B - OC-804 FOR OFFICIAL USE ONLY Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE TO: FACILITY GRIEVANCE COORDINATOR FACILITY: DATE: f ; FROM: (INMATE NAME & NUMBER) SIGNATURE of INMATE: WORK ASSIGNMENT: HOUSING ASSIGNMENT: } INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. a- t A i B. you ave con'acte before su ml Ing this gnevanc - u Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised December 2000 DC-804 FOR OFFICIAL USE ONLY part 1 COMMONWEALTH OF PENNSYLVANIA -- - , DEPARTMENT OF CORRECTIONS : t/" P.0. BOX 598 1 " i I CAMP HILL, PA 17001-0598 GRI VANCE NUMBER i OFFICIAL INMATE-GRJFYANCE , TO FACILITY GRIEVANCE COORDINATOR fi FACILITY: DATE: n-- FROM: (INMATENAME & NUMBER) SGNATURE of'INMATE: SSIGNMENT I -WORK ASSIGNMENT-.- H?]LTSIhIGASStGNME NTr` ? 'mob./ Y -MYM tx^i. A+wY t'-•4hJl C x INSTRUCTIONS'.- " r -->? - 1 _Refer:to-theDCADM-B04•fior,prpcedufe'9,„dn,-dheWmategrtivancesystem.. 2. Statagoui-grtevance try Block A in a k?rief_at11#„6xt]>1eCSt dable', ar?ner 3. List-in Block-8+any°actions-you maytiave>takdiT??!res- a hrs aala?ter Be stare to include the identity of staff members.yowl'have-zontacted.- - A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. r 8. List actions taken and staff you have contacted, before submitting this grievance. Your grievance has been received and will be processed in accordance with DC-ADM 804. r" Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised December 2000 DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598;:_.. i _ GRIEVANCE, NUMBER OFFICIAL INMATE GRIEVANCE TO: FACILITY GRIEVANCE COORDINATOR FACILITY: DATE: FROM: (INMATE NAME 8 NUMBER) SIGNATURE of INMATE: WORK ASSIGNMENT: HOUSING ASSIGNMENT: INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. B. List actions taken and staff you have contacted, before submitting this grievance.- Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised December 2000 L4 COMMONWEALTH OF PENNSYLVANIA Department of Corrections SCI-Fayette October 6, 2004 .=?> SUBJECT: DC-ADM 802 Administrative/Pr tive Custody Appeal TO: Alfonso Pew, #BT-7263 LC-2018/1 FROM: Ha E. Wilson Superintendent I am familiar with the Policy DC-ADM 802 that you are referencing and it is my interpretation as well as PRC's that you haves entitlement to any personal proPe y It is PRC's opinion that yo cu an return to general population and refuse to erefore, your placement in the RHU is a result of your behavior. Your appeal under DC-ADM 802 is denied. HEW:mab cc: Program Review Committee Mr. Waggoner (A) DC-15 DC-804 COMMONWEALTH OF PENNSYLVANIA Part 1 DEPARTMENT OF CORRECTIONS FOR OFFICIAL USE ONLY - ? BOX 598 O P • "' . . CAMP HILL, PA 17001.0598 `GRIEVANCE NUMBER Cflit,iE OFFICIAL INMATE TO: FACILITY GP4EVAN19,ffINAT? _ FACILITY: DATE , r FROM (INMATE NAME & NUMBER) SIGNATURE, of INMATE WORK ASSIGNMENT: HOUSING ASSIGNMENT: INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. State your grievance in Block Ain a brief and understandable manner 2 . 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper A ' . /z' x 11 page). may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8 ------------------------- S. List actions taken and staff you have contacted, before submitting this grievance. -? Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August2004 DC-804 COMMONWEALTH OF PENNSYLVANIA FOR L USE ONLY Part 1 DEPARTMENT OF CORRECTIONS 598 / X 01-0598 7 0 L (ucyt Ct-- CAMP HILL, PA GRIEVANCE NUMBER OFFICIAL INMAT T ' FACILITY F I TY DAT ?. FR M:(I ATE M NUM BE )- _ S Eof INMAT W R ASSIGNMENT: HOUSIN SIGNMENT' INSTRUCTIONS: 1 2 St at ijGl gria =61E 141148, .0 `@I,w 3 me Provide a brief, clear statement of yob State all relief that you are seeking. Additional paper A . may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'/2' x 11" page ???1sc J l 0 a - ?, Niter fns I&- ? C,..) Fe-N 2_ ??• }?= L'-? 4-MCA-tziij A,[\-) T ccx-y wat .-4 z+? s? t c' ? -o t? N s al a u? ?f ?` >??v = '0 CQ A =' k t.- a. _ T ?i to Vv. ?C B. List actions taken and staff you have contacted, before submitting thi Q)\? '? bl ' edv\Cb e6?- ?? 6p tSSUC d P- z? h C?iZLFP Crr_? itl t?SCz e ? ?h? bb z?G '- bo th sl,? G' ? -4c zMQ'k. k) - ?? t >Y?. pl 'Its a? p' PGA ? u? Y)o-n6 C,?a auj6 ry `E, LeCQ t l -? ? •-? ac t -??i?-? ? ?c,uvc? ?.?t- ? -?- t-,-•? ? l cr.? Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August2004 DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY - Part 1 DEPAI,TMENT OF CORRECTIONS- - ,P - BOX 598, O . . CAMP HILL PA 17001-0598 -°. GRIEVANCE NUMBER i --- 4 G i NCE1 RIEV OFFICIAL INMATE. TO FACILITY GRIEVANCE`.M0RDINATOR ,,. FACILITY - DATE: ' (INMATE NAME & NUMBER) FROM: SIGNATURE of INMATE: s WORK ASSIGNMENT: HOUSING ASSIGNMENT: INSTRUCTIONS:"` 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may'have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 81/2' x 11" page). ..4 a -_ 1 - 1 l I ` B. List actions taken and staff you have contacted, before submitting this grievance. Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator WHITE - Facility Grievance Coordinator Copy CANARY Revised August 2004 Date File Copy PINK - AcEon Return Copy GOLDENROD - Inmate Copy DC-804 COMMONWEALTH OF PENNSYLVANIA Part 2 DEPARTMENT OF CORRECTIONS P. 0. BOX 598 CAMP HILL. PA 17001 OFFICIAL INMATE GRIEVANCE INITIAL REVIEW RESPONSE TO: (Inmate Name & DC No.) FACILITY SCI-FAYETTE GRIEVANCE NO, 102346 The following is a summary of my findings regarding your grievance: 11/21/04 COMPLAINT: The inmate states he wants a therapeutic diet and to see a cardiologist FINDING OF FACT 1. SCI-Fayette has a healthy diet established by the BHCS. 2. There h_ a®o referral written for ou_y to see a cardio?loglst. Th medical director of the inmate will OeGIOe IT or Wnen on IS nee a .. Conclusion: no merit. DECISION: Grievance denied. SIGNATURE-OF GRIE NCE OFFICER O ' a04 cc: Superintendent Deputies DC-15 (Records) Grievance Coordinator File Print Name and Title of Grievance Officer R. Tretinik, R.N., Corrections Health Care Administrator Y HOUSING LOCATION I-i wek-- GRIEVANCE DATE ?ECE?'0 DATE tig 2?? 11/24/04 DC-804 COMMONWEALTH OF PENNSYLVANIA Part 1 DEPARTMENT OF CORRECTIONS FOR F IC JA_L USE ON P. O. BOX 598 - C1 1 OFFICIAL N.CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER TO FACILITY F C TI, DAT ?` . FRO :(I M TE AME & NUM ER +ib=- T R of IN TE: WORK ASS NMENT: H SING S E _ INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'/2' x 11" page). t ?S C LJ ?34 C r=- eec (O FIC") :Z: - - l? 4 c C C. -A- cc) (,CQk SOL ? 12{? - 'v C C US ?' C 1?3 B. List actions taken nd staff you have contacted, before submitting this grievance. Lkl) V / Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 i? cC? t? t ` `CP? r?I it DC-804 COMMONWEALTH OF PENNSYLVANIA OF CIAL U NLY Part 1 DEPARTMENT OF CORRECTIONS P. O. BOX 598 CAMP HILL, PA 17001-0598 VANCE Nl OFFICIAL r = - T ACILIT F I T DATE: - q --nLA ,. FR M'. (I TE & UM?E_ N U E of INMA WOR ASSIGNMENT: H USI S GNMENT: Qt-A - INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have taken to resol e this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your_gaisiir?es State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one one-sided 8'12' x 11" page). 00 S N h? SS 1>r t MA 1s ? Q0S6 i6 FJ C 6 ? 4 C? . 4, Z `'y !`?' `ham t E ?Q`` Lc?¢c p wt ? , a c K Z Q Jf.T Q 0 C (' , ?.t'j Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August2004 uu-°uµ COMMONWEALTH OF PENNSYLVANIA Part 1 FOR CIAL ONLY DEPARTMENT OF CORRECTIONS \\ P. O. BOX 598 }CAMP HILL PA 17001-0598 IEVANCE N , OFFICIAL INMA l UMBER TO: LIT tf FpCILI? C FROM (INM AVE & NUM C'?k SIIGNAT , o IN ATE: {? "'L 11 K3 WORK A IG NT: HO}US G ASSIGN N t \S \ INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. a. . A. Provide abrief, clear statement of you?V?. State all relief that you are seeking. Additional paper may be used, maximum two,papes. (One DC-804 Part 1 form and one, one-sidep 8'/2" x 11 page). j \ IS, - ? L1.1 L \ Jc? ek-- ?Q J \ B. List actions taken staff you have contacted, before submitting this.gr- cl? Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date 1-4 WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 - ?`-? COMMONWEALTH OF PENNSYLVANIA Part 1 FOR AL U DEPARTMENT OF CORRECTIONS {,'}I P. O. BOX 598 jL ,?? ? - CAMP HILL PA 17001-0598 ANCE R , OFFICIAL TO: FACILITY FACILITY: DA F OM- IN & UMBER) SI T E I INMA E WO K A%SSIGNMENT: ?J S NME INSTRUCTIONS: 1. QA 41 RtR E M. 2. Gtal? _ 3 . A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, ma imum two p ges. (One DC-804 Part 1 form and one, one-sided 81/ " x 11" page). ?? ?_ ? t n ACA\\/ 2u w J A iC? ?- " l - ? ? l3 G l? ,G y C C i LQ Ul'3 Jp' sic ? l Eli C , C? S di t s P B. List action taken and staff you have co ctedpefore bmitting this grievance. 2 _ 1 L--1y ? q NArPFwS V . -•?' Yo levance as een receive an wil e prose accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 (r--x k f le> `r Sri) DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA OFFICIAL ONLY DEPARTMENT OF CORRECTIONS P. O. BOX 598 OFFICIAL ?` RSrC AMP HILL, PA 17001-0598 G ANC MBER TO ACIL C F CIf?TY? DATE- ` ay FRO : (I AME & NU )= SIG INMAT t ? r WORK ASSIGNMENT- t2PIN AS GIN INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have oaken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement Of you Sta e all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'/2" x 11 page). `c i? ?? ? ? Iv (? ICJ ??-? c ^ra °? Vic , , B. List actions taken and staff you have contacted, before submitting this grievance. u?l l h _ lr ' 1 J ?- Cv 2sz&c?tc?? l C?;?c? c ti -r-h F Yv? ACS t v? l T F -?- 4r--0k Y,2N1 ? u?l` Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 t (Ex i--I IL I+ Lis) DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS P. O. BOX 598 CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER OFFICIAL INMATE eSEMIll TO I ITY LY DAT \ FR M: ATE NAME & N M R r SI of NMATE: WO SIGNM HC USING ASS INSTRUCTIONS: 2. 3. L' A. Provide -- ?mav b 41 ^ - Qi) G 1v - p 1 w z ?' CGS C P-c-J. C B. List actions taken and staff you have contacted, before submitting this gri 5a cn e . y'(-' - , Your grievance has been received and will be processed in accordance with D Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator COPY CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August2004 Q n DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS !/ ?^ ?_ P. O. BOX 598 C.e, 5 c.:.}? CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER 6 - OFFICIAL INMAT TO: CILITY F ILI Y: DATE: FRO : (IN NAME & R) a`?-?? SIG INMATE: ?'- WORK SSIGNMEfjm OUSING? - M t T; INSTRUCTIONS: 1. 2- _ ---? s aff 3. iSi in nr A. - aper i?? C? -I LAI 6-C-2 ciV B. List actions taken and staff you have contacted, before submitting t is grie ance x-^?T (C' W?2 t 4L ?V v LAI)?? Your grievance s een received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHJTE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 DC-804 f?Part 1 OFFIC !?. COMMONWEALTH OF PENNSYLVANIA ?y DEPARTMENT OF CORRECTIONS P. O. BOX 598 CAMP HILL, PA 17001-0598 TFACILIT CILITY: FR M MATE N ME & UMBER A E of INM TE: - WO K SSIGNMENT: ISE' H USI SIN INSTRUCTIONS: 1. fQF 2.r 64a3e yaurtipxagB° ° n' o h' f i n eT°°??i? 3. .. ff A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'/2' x 11" page). +Q ce? L 'a e?-fCc c?(-??r C= ,s B. v 0-0 it .e Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS SCI-FAYETTE January 13, 2005 SUBJECT: Response to First Level Appeal Grievance # 102346 TO: Alfonso Pew BT-7263 FRO jHa . Wi lson ntendent I am in receipt of your grievance, #102346, dated 11/23/04; the Initial Review Response by Mr. Tretinik, CHCA, dated 11/29/04, and your first-level appeal received in this office on 12/10/04. After careful evaluation of the attached grievance, it is the determination of this Superintendent that the action and response provided by investigating staff will be upheld. I find the issues, raised at first-level appeal, were addressed appropriately and responsibly by staff at initial review. SCI-Fayette Dietary Department prepares and serves a healthy diet menu established by the BHCS. There is no longer a need for inmates to recommend a thera eutic diet. Your Medical Recor was oroug y researched an the re bas pen no referral writte for you to see a car o ogist. For these reasons, your appeal is dismissed. HEW/mab Cc: Ms. Scire DC-15 ,m - e" ?S W, `-? DC-804 Part 1 r rwunnrc !_CIC\/ANf`F COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P. 0. BOX 598 CAMP HILL, PA 17001-0598 r- T FACILIT F 'IL?TY DA2T - FRAM: ( M E NAM & UMBEFI) SI of INMATE W RK ASSIGNMENT: HOUSING IGNtINT: L C vZ? INSTRUCTIONS: 1. 2 3. A. Provide a brief, clear statement of-yA0PjF*vmrce. State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'!2' x 11" page). \t c. LI ?N(.CR.?.? ? 1E- n - alt ' i • !z- S , ?L t ? ? Y?IM a$ lC ( c .7 1 0 B. List actions taken and staff you have contacted, before submitting this g4. ?? w1C W YZ v A?C = - -r-?- --ghese CG, ?r\4"N lA .'v k C FF z _ K ? G'z V-1 ,? I S h tcc,r? dViSt!'t? Cow?f G? {ECG SCE {'Ctic v? ` W?CL1 / Your grievance has been received and will be processed in accordance wltn UU-AUNi bU4. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 uu-OV4 COMMONWEALTH OF PENNSYLVANIA Part 1 r DEPARTMENT OF CORRECTIONS (/`?? Ny P. O. BOX 598 FO FICIA SE ONLY L. ft 8?1` CAMP HILL, PA 17001-0598 FFICIAL INMATC GRIEVANCE NU TO' ACILITY F TY? CAT FR M:.I ATE NAME MBE? iI S E INMATE: W R ASSIGNMENT: HOUSI GA IG EN : INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. y .,u .,. r,.o .?,.. ?.. KA - k&A 2 b B-.Li&L-QLoQ&4a4ke.. and staff t. i 1:211c?A 1 . i rz' Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date V WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 SUBJECT: Re-Issue of DC-ADM 007, "Access to Provided Legal TO: All Inmates le ? FROM: Jeffrey A. Beard, Ph.D. Secretary ----4 TH OF PENNSYLVANIA iartment of Corrections Secretary's Office (717) 975-4860 u S.C.I. FAYETTE LEdAL LIBRARY This notice is to inform you that the Department has revised the DC-ADM 007, "Access to Provided Legal Services" policy. This version supersed s the QC-ADM 007 policy issued September 8, 2003, by Secretary Jeffrey A. Beard, Ph. D.7 I Changes to the policy include: 1 B. 3. - The last sentence now reads: "Research periods will a scheduled and assigned in time blocks of two hours each, for a maximum of six hours per week." B. 4. - Now reads: "A Mini Law Library shall be availaple for I gal research seven days a week, eight hours per day, as needed." C. 1. a. - "A maximum of three published case opinions per eek" was added. C. 3. -"An inmate may request a maximum of three library paging system" was added. C. 7. b. - Now reads: "include a timely schedule for (delivery of opinions from the facility's Main Law Lit Paging System will be made weekly to an inmate h C. 7. c. - Now reads: "permit a maximum of three cii delivery from the Main Law Library or the State Law thereof, per This new policy will go into effect on November 26, 2004 and is 0ailable in the library for you to review. You may also "check-out" a copy of the policy fro the library as you would a library book. If you want a personal copy, you may pure ase onl? using the copying procedures at the facility. The cost of the copy will be 10 ?ents per page. Any questions you may have about this policy should be Officer-in-Charge of your housing unit. cc: File copies per week from the ry of requested legal materials ide the Comprehensive in restricted housing unit)." your Unit Manager or Our mission is to protect the public by confining persons committed to our cru.stodv in .?,a/e, secure.Jacilities. and to provide opportunities for inmates to acquire the skills and values necessarv to become productive lair-chiding citizens: while respecting the rights ofcrime victims. L Le:L- ? ) DC-804 Part 1 OFFICIAL INMATE GRIEVANCE COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY GRIEVANCE NUMBER TO FACILITY GRIEVANCE COORDINATOR FACILITY: DATE: FROM: (INMATE NAME & NUMBER) SIGNATURE of INMATE: WORK ASSIGNMENT: HOUSING ASSIGNMENT: INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may 1?ave taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. ------------ B. List actin a en -s a you have contacted, before submitting this grievance. Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised December 2000 917T .6b) DC-804 COMMONWEALTH OF PENNSYLVANIA Part 2 DEPARTMENT OF CORRECTIONS P. 0. BOX 598 CAMP HILL, PA 17001 OFFICIAL INMATE GREIVANCE INITIAL REVIEW RESPONSE GRIEVANCE NO. i 111274 L TO: (Inmate Name 8 DC No.) FACILITY HOUSING LOCATION GRIEVANCE DATE Pew, A. BC7263 SCI Fayette L-Unit March 2, 2005 The following is a summary of my findings regarding your grievance: COMPLAINT: The grievant reports that he is no longer permitted to use the law library in L Unit with another inmate. FINDING OF FACT: According to DC ADM two inmates to use the Mini Law Librarv Sim DECISION: Grievance Denied. 1 %N 2005 CC: Superintendent Deputies DC-15 (Records) Grievance Coordinator File Please Note: You have five days to appeal this grievance decision to the SUDerintendent. Print Name and Title of Grievance Coordinator Eric T. Armel, Major of Unit Management SIGNATURE OF GRIEVANCE COORDINATOR DATE March 7, 2005 irk DC-804 COMMONWEALTH OF PENNSYLVANIA Part 1 FOH FFICIAL E ONLY " DEPARTMENT OF CORRECTIONS P. O. BOX 598 _ c AMP HILL, PA 17001-0598 OFFICIAL INMAT TO' CILIT .911T D- 6.T -- i FRO : (AT NAME & N R) i^ ?YnV? b E of INMAT r1 ? WO K SSIGNME T: HQUSIN A IGNM NT INSTRUCTIONS: 1. 2. 3 0 11 . - 7 mopp6opq R A . ° e- ?' L.v rnClJ ? Cj?S S -1-, . ? S G C t?? ?r?'i _70. • LZS .TM ? ?h? y B. YNAC Ccx?c ?. lvtco?a ?yZ F ?u?? ?i??Cn ?, ca.zc ?-? ? r?a1?c?(d .,. C c? ?Z '??15 .SuPP 2? 52'l C( S?,?z,4, v Gcc?a 2SS ?? uPP ? ti2 S?-i?N?( 2C3C3?? Ci) Mc,cC-v_ C?uc?Q-? ZS ?2? L O zc l <S •? ti?o 2C3C;?? C_ Suv P ? ??? La.hl_14 ZG(i: 0--ml-p1w ling C C li::'k q-, s To D 'E?7(-Af c c • V7? \?- " -CL? DC,_p ?-k ?O?€` 1 c)cl v? Npc, c >j ?j C (j August 2004 -?- V?/ c.25 W ? ?E 4 -? _U ?C ?G P` v?nl 1 ?;.?{ P-L-?uuc' Sf-_ - t?R ?hL 'Z?1X ? CZS >? U(:-804- COMMONWEALTH OF PENNSYLVANIA Fart 1 DEPARTMENT OF CORRECTIONS FOR P. O. BOX 598 y?,•,, \ C P HILL P 17D-059 -.9q OFFICIAL T ? FACILITY - -- ' E: _ FR M: (I M T AVE && LIMB R) vv S11 A U E of INMA E: .L51 /? WO KSSIG MENT: HOU N SSIG E T. L - l INSTRUCTIONS: 1. 2. 3. A 2424Q %I! I f th ! . FB o e !am al 6( G k? A- -Ja ?'N SF-12? L G ? v,-, i t.r \ b 1 j ?.t G 2 c ? - . _ lti Cam' ?,? P-(-Q Ali a w - ( ?c r.1G B.. olres ???_ i??? i? ,S CL i rV VCa aAlC?.Sr ? Cu t 41- y 1 1 ry { h Wuc? ?' f" Zvi Nb t C J\? zu, 2 ? C C'S -• , tr` ?C7 Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator R OFFICIAL U g' pNLY V 1 ?? 1 ti- Date C WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 Lo. ?,, C-Qc? 4zl-t? CL ?C ia:3- _w r DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF CORRECTIONS P.O. BOX 598 CAMP HILL, PA 17001-0598 FOR OFFICIAL USE ONLY - GRIEVANCE NUMBER vrrj,Ji L. I T" I VA CE 00 O LT DATE F IN E NAME 8 N MB R) of INMAT NMENTt SI(? T - OUSIN IGNMENTx 1?\?J INSTRUCTIONS: I 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. Additi a pape may be used, maximum o es. - ;? CL L 46 M? CCA?v1 ?1v`?? ?CC_' C' C?.kc,U?Sc CIO SA CU0 t"' - - B. List actions taken and staff you have contacted, before submitting this e ? e. ?C [ Your grievance has been received and will be processed in accordance wan uL;-AUM oU4. Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD- Inmate Copy Revised December 2000 (ExHIL 1,j? r 19 ?J Department of Corrections INMATE'S REQUEST STAFF MEMBER I 1 INSTRUCTIONS Complete items number 1-8. If you follow instruc tion 'n ) preparing your request. it can be respo t - --?L om tl and intell: e: y 1.o: (Name Titl .of f ricer) 2. Date: i, ate N m"nd Number) 3. B : ri t I 4. Counselor's Name \ I ? ( ? 5. Unit Manager's Name ??... -_.1-?•c+-ems .w Inmate Signature 6. Wor sign nt 7. Hou rag ASS nment Subject', State our request com letel ,but briefly. Giv. -- ZV? 1A C Q C, 'A, C4 i >. il i --K CD F 9. Res onset This Section for Staff Re se b4) :1 4N? P\ 1 1 1 ry ?" 1 To DC-14 CAR only ? To DC-14 C R and DC-15 IRS ? Staff Member Name ?. fl n - Date " I / v 4 Print Sign Revised July 2000 M ? ? ' ?)) =art 1 - FOR OFFICIAL USE ONLY I '3,P art 1 h C MMONWEALTH OF PENNSYLVANIA Ak'- r- " EPARTMENT OF CORRECTIONS P.O. BOX 598 CAM II HILL, PA 17001- 9 GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE tv-- `1C G FACILI GF VANCE COORDINATOR DATE L 4 L - M' 1 TE NAME & N M ER) y F RQ T RF1 of INMATE: i \ WO KA4SIGNMENT: HOUSI IGNM , Me, INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statemen of your grievance. Additional paper may b used, maximu two ag s. ,`cam e cv LC e -, tit C-' i? \ QIt! L -3 '-IL4 e submitting this grievance. -- C T-\'. cc'Q .c c ?; ??c , ? ??? ?c CJt? C--_ - +? e Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date 1 WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised December 2000 DC-804 Part 1 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY DEPARTMENT OF CORRECTIONS I i . P.O. BOX 598 CAMP HILL, PA 17001-0598 GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE TO: FACILITY GRIEVANCE COORDINATOR FACILITY:,_ ,..-_.... DATE: FROM: (INMATE NAME;B NUMBER) SIGNATURE of INMATE: -Ij k le WORK ASSIGNMENT: HOUSINGASSIGNMENT INSTRUCTIONS: 1 Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner. 3. List in Block.B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. 11-_ ; A. Provide a brief, clear statement of your grievance. Additional paper may be used, maximum two pages. !rt { B. a- en an s a, you. aye-contacted, - before submitting this grievance. Your grievance has been received and will be processed in accordance with DC-ADM 804 Signature of Facility Grievance Coordinator Date WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK -Action Return Copy GOLDENROD -Inmate Copy Revised December 2000 DC-804 COMMONWEALTH OF PENNSYLVANIA F ICIAL USE 0 Y Part 1 DEPARTMENT OF CORRECTIONS P. . 0. BOX 598 CAMP H 1-0598 GRIEV E NUMBER OFFICIAL INMAT TO F CILITY S {, F I ?TY: DAT FRO t'. (I E NAME & N SIG E f INMATE'. W RK SSIGNM )USING- l a E INSTRUCTIONS: 2 3. A. Provide a brief, clear statement of you State a I relief that you are seeking. Additional paper may be used, ma mum two pages. (On_e` DC-804 Part `1 -form and o on sided 8'/2` x 11" page). ?C J tj '?C)' _ Nr` ?a 1?1 ) _ JJL B. List actions taken yandstaff you have conit?aVcted-?be^fo/r}e submitting tyhis`griev ? ?.{?v?-i1,i C-]-?JC"? /?'? 1vv`V S? v E6 ? 1S N C ? ? - s ? E SZ?v sp`?Er?,?K f A-0 Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 DC-804 Part 1 ? l 60MMONWEALTH OF PENNSYLVANIA ( U lr `DEPARTMENT OF CORRECTIONS OR OFFIC L E ONLY f BOX 596 P O . . If CAMP HILL, PA 17001-0598 (EVAN MBER OFFICI - TO: CILIT F TYt? D TEi i FRO :(I TE NAME & NN B R) ?r SI ?T I INMAT y? OR ASSIG M T: HOUSI G A SI E INSTRUCTIONS: ?. 2 3. A. Rler 36 ?f? v r ` ?y? V Cam(\. 1/? `'?? 01, 9 ?A} B. List actions taken nd staff you have r?ontacted, efore submitti g this ?rievan e. 1 r r ? /tea Ir? ?k (AV Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date Y WHITE -Facility Grievance Coordinator Copy CANARY - File Copy PINK- Action Return Copy GOLDENROD- Inmate Copy Revised August2004 _ t c p ' ,r^ DC-804 COMMONWEALTH OF PENNSYLVANIA FOIR OFF}ICIAL USA ONLY I r i. t Part 1 DEPARTMENT OF CORRECTIONS y r t t-, `C??? .. - P. O. BOX 598 1 _, a i :•C_ j?"-?1? ?+-r??-1-h4.,.? C ILL 170 - ?(± -6g?}1.€?aW .. _. 'Ai16.P.••- OFFICIAL, - TD' FACILIT ! i ? ' .17 1 4 _1 ._! [ wi ._ FRO (INM?(??E NAME & BER) ,y^,.?% q t SIG ?TI??tF?uof INMATE: a?. ,-•. „ K/[ASSIGNMENT: WOtR HQUSINGASS,IG E,?N(T. SG,?FAycT T ? l : \ F (7i'2 INSTRUCTIONS: u ? n annf ` , , , tL?r 1,_._44efer , . 2. 11 _S3a ?Jee#aw?ci ?la+ada?41ar4rle?, (P ?? i 3. -_ !St f] Rlnnk R?? ?,?mGnFlS uQypp? TQ tBdFi ' ' TEt'dD- m?mhP ed. _e?_hFwsleacst •?9f?i'.NaTa© are'E tiflr?alS?pec A. ?rcwd __, mabbe-usgg6- a ' SQ L ?r n anc? n?? or3 =;s t °.tiT - ; Pags? Cj ? - f t_C t'Gt T _A,?F J'.tQ r e &? _ ?' ? 4 at4 "A6. (,. l.,e-._Y -{-.AJ?_ P..3 `- ?v? v, t?..i.?...- f`,?'-r'f•'' " ''?. ('- `t"' ?'`' t_ c v,77? 7 f (7 r C_e! bF ti_. 'far Lr,1<? c ; ?Arv C U C 1, i? T-.1` ..:}_. t. ?1_• y? $r _., ?`C. CC! ',.I Ica_ V( r t i? Cu_ 757e 1 J L' t,_. B. List ar}rnnc akon an(j ?yf#ygl}{q htt ft? ?T t ? s c r t r? v. Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS C CC P CAMP HI . BOX 598 LL, PA 170 7001-0598 a".e. ei rsr. AGILITY G V CE OO DINATOR C Yi D ?l FFkM= (I MA E NA E & N R) A RE I INMATE: W RK IGNt? FjOU51f, INSTRUCTIONS: 1 3 entit . A. c ,C Co, \N, C t? -? ? ?? _ E COQ c. 72T 7 7'e--- , , B. ,1 ict rtinnc t La n i ct ff ynu h^ a f °S^'° ^ '? °"" rti;^ " C VC Your grievance has been received and will be processed in accordance with DC-ADM 804. Signature of Facility Grievance Coordinator Date WHITE - Facility Grievance Coordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy Revised August 2004 DC-804 COMMONWEALTH OF PENNSYLVANIA FOR OFFICIAL USE ONLY Part 1 DEPARTMENT OF CORRECTIONS ' BOX 598 P O . . - CAMP HILL, PA 17001-0598 - GRIEVANCE NUMBER OFFICIAL INMATE GRIEVANCE INATOR TO:.FACILITYGRIEVANCEC T -:' -- F DATE: f lE k E NAME & NU) FR OM(INMAT # of INMATE „ i k s t WORK ASSIGNMENT; SSIGNMENT INSTRUCTIONS: 1. Refer to the DC-ADM 804 for procedures on the inmate grievance system. 2. State your grievance in Block A in a brief and understandable manner 3. List in Block B any actions you may have taken to resolve this matter. Be sure to include the identity of staff members you have contacted. A. Provide a brief, clear statement of your grievance. State all relief that you are seeking. Additional paper may be used, maximum two pages. (One DC-804 Part 1 form and one, one-sided 8'/2" x 11 page). i e k li B. List actions taken and staff you have contacted, before submitting this grievance. Your grievance has t Signature WHITE - Facility Revised August 2004 received and will be-orocessed.in_accordance with DC-ADM --- -- ? Grievance Coordinator Date oordinator Copy CANARY - File Copy PINK - Action Return Copy GOLDENROD - Inmate Copy I IN THE COURT OF COMMON PLEAS OF n Q? COUNTY, PENNSYLVANIA lv t 4001? DIVISION AUv - '' vs No.L n Defendant PETITION TO PROCEED IN FORMA PAUPERIS TO THE HONORABLE JUDGES OF THE ABOVE NAMErrJCOURT: i, Jl AND NOW COMES the Petitioner, ,CrF-? 1 pro se, who respectfully represents the following: 1. Petitioner contends that he is unable to afford the costs and fees necessary to prosecute the above captioned matter. 2. The affidavit showing my inability to pay the costs and fees of litigation is attached hereto. WHEREFORE, Petitioner prays that this Honorable Court will allow him to institute this action and proceed to the termination thereof, In Forma Pauperis, or without the payment of filing fees, costs or giving security therefore. Respect ully mitted & ( ( I - ?- v'?- ?A Q-N\? Pro Se 090001M f7-t-V VERIFIED STATEMENT I r-?\\'e(-,i-fSe by 18 Pa.C.S.A. §4904 state that under the penalties provided sificaticn to authorities) that: 1. I am the defendant in the above action and because of my financial condition am unable to pay the following fees and costs: appellate filing fees, costs of reproducing records or briefs. 2. My response to the questions below relating to my ability to pay the fees and costs of prosecuting an appeal are true and correct. (a) I am presently employed at the Institution as a N U )?J& My salary is $_.00 per month. (b) I have received no other income in the past 12 months. (c) I have no cash other than inmate wages; I do not have a checking or savings account. (d) I do not own any real estate, stocks, bonds or a motor vehicle. (e) I have no dependents. (f) I have no debts or obligations. 3. I understand that a false statement or answer to any question in this verified statement will subject me to the penalties provided by law (misdemeanor of the second degree). Dated: ?_/ %*a/Or, i PROOF OF SERVICE C.? hereby verify that I am this day serving the foregoing document[s] in manner listed below which service satisfies the requirements of Pa.R.A.P. 121. This service also satisfies the requirements of the Prisoner's mailbox act[ (Com, v. Jones 700 A.2d 423; Houston v. Lack 109 S.Ct. 2379): Service by First Class Mail: C -1k c?,--- ?? C: C Dated: ;?-_/ ? -,- /06 rb, } { y? ?S 0 ox 9990 PA 1??c( PA DEPT . OF CORRECTIONS INMATE ACCOUNTS SYSTS'M RUN IAS365 BUREAU OF COMPUTER SERV ICES PARTIAL ACCOUNT LISTING DATE,. 2/23/2006 REMOTE PRINT TIME 7.2.16 FROM PURGE FILE PAGE 1. INM ATE NAME NUM BER LAST FIRST MI STARTING BALANCE, BT7 263 PEW ALFONSO -25.19 BATCH DATE TRANSAC TI ON BALANCE AFTER # MO DY YEAR TRANSACTION DESCRIPTION AMOU NT TRANSACTION 9276 10-03-2005 10 INMATE EMPLOYMENT FYT PAYROLL 2005 -- 09 GRP 1 12. 96 -12.23 3488 10-04-2005 37 POSTAGE 1.0/02/05 -- 60 -12.83 3488 10-04-2005 37 POSTAGE 10/02/05 -1 .06 -13.89 3488 10-04-2005 37 POSTAGE 10/02/05 4 X .37 -1 .48 -15-37 3488 10-05-2005 37 POSTAGE 10/3/05 5 X .37 -1 -85 -17.22 3520 10-12-2005 37 POSTAGE 10106105 2 X .60 -1 .20 -18.42 3520 10-13-2005 37 POSTAGE 10/07/05 2 X .83 -1 .66 -20.08 3538 10-14-2005 13 PERSONAL GIFT FROM HARRIS, SHERLEE H588973 25 -00 4.92 3549 10-18-2005 37 POSTAGE 10/16/05 - .60 4.32 3549 10-18-2005 37 POSTAGE 10/16/05 3 X .37 -1 .11 3-21 3487 10-26-2005 41 MEDICAL SICK CALL 10/24/05 -8 .00 -4.79 3581 10-27-2005 13 PERSONAL GIFT FROM KEEL, MARCELLA H594710 40 .00 35.21 8300 10-27-2005 34 FYT CABLE TV FOR 10/27/2005 -15 .25 19.96 3601 10-31-2005 37 POSTAGE 10/26/05 - -37 19.59 3601 10-31-2005 37 POSTAGE 10/26/05 -2 .44 17.15 3601 10-31-2005 37 POSTAGE 10/28/05 -1 .52 15.63 9305 11-01-2005 10 INMATE EMPLOYMENT FYT PAYROLL 2005 - 10 GRP 1 14 .40 30.03 3601 11-01-2005 37 POSTAGE 10/30/05 -2 .44 27.59 3601 11-01-2005 37 POSTAGE 10/31/05 - .37 27.22 3601 11-01-2005 37 POSTAGE 10/31/05 2 X 4.75 -9 .50 17.72 3601 11-02-2005 37 POSTAGE 11/01/05 - .23 17.49 3624 11-08-2005 37 POSTAGE 11/03/05 - .60 16.89 PA DEPT . OF CORRECTIONS INMATE ACCOUNTS SYSTEM RUN IAS365 BUREAU OF COMPUTER SERV ICES PARTIAL ACCOUNT LISTING DATE 2/23/2006 REMOTE PRINT TIME 12:16 FROM PURGE FILE PAGE 2 INM ATE NAME NUMBER LAST FIRST MI BT7 263 PEW ALFONSO BATCH DATE TRANSACTIO N BALANCE AFTER # MO NY YEAR TRANSACTION DESCRIPTION AMOUNT TRANSAC TION 3229 06-03-2005 37 POSTAGE 8/1/05 -.60 104. 18 3229 06-03-2005 37 POSTAGE 8/1/05 -1.29 102 .89 3229 08-03-2005 37 POSTAGE 8/1/05 -1-06 101 .83 3230 08-05-2005 34 RADIO/TV FYT CABLE TV - AUGUST -15.25 86 .58 8222 08-10-2005 86 FYT COMMISSARY OR 32 FOR 8/10/2005 1-00 87 .58 3278 08-11-2005 36 PRINTED MATERIALS SPEAR & SHIELD -6.00 81 .58 3278 08-11-2005 36 PRINTED MATERIALS PUB OF NATION TIME -7.00 74 .58 3263 08-11-2005 37 POSTAGE 8/09/05 3 X .37 -1.11 73 .47 9227 08-15-2005 10 INMATE EMPLOYMENT FYT PAYROLL 2005 - 08 GRP 1 7.92 81 .39 3283 08-15-2005 37 POSTAGE 8/09/05 --37 81 .02 8227 08-15-2005 32 FYT COMMISSARY FOR 8/15/2005 -18.17 62 .85 0 08-19-2005 82 TRANSFER OUT FAYETTE 0 08-19-2005 81 TRANSFER IN WAYMART 3651 08-19-2005 37 POSTAGE --80 62 .05 8237 08-25-2005 32 WAM COMMISSARY FOR 8/25/2005 -33.86 28 .19 3708 09-01-2005 37 POSTAGE -1.98 26 .21 8244 09-01-2005 32 WAM COMMISSARY FOR 9/01/2005 -24.90 1 -31 3735 09-07-2005 37 POSTAGE --37 .94 3735 09-07-2005 37 POSTAGE -.37 .57 3735 09-07-2005 37 POSTAGE -.37 .20 0 09-12-2005 82 TRANSFER OUT WAYMART O 09-12-2005 81 TRANSFER IN FAYETTE PA DEPT. OF CORRECTIONS BUREAU OF COMPUTER SERVICES REMOTE PRINT TIME 12:16 INMATE NAME NUMBER LAST BT7263 PEW BATCH 7378 7378 `7387 O O 7548 7556 INMATE ACCOUNTS SYSTEM PARTIAL ACCOUNT LINING FROM ACTIVE FILE FIRST MI ALFONSO RUN IAS36S DATE 2/23/2006 PAGE 3 DATE TRANSACTION BALANCE AFTER MO DY YEAR TRANSACTION DESCRIPTION AMOUNT TRANSACTION 02-14-2006 37 POSTAGE WEEK ENDING 02/18/06 -2.07 02-14-2006 37 POSTAGE WEEK ENDING 02/18/06 -4.20 02-16-2006 38 INSIDE PURCHASES XEROX COPIES 2/13/05 -.60 02-21-2006 82 TRANSFER OUT SMITHFIELD 02-21-2006 81 TRANSFER IN ROCKVIEW 02-22-2006 37 POSTAGE FEBRUARY -4.05 02-23-2006 13 PERSONAL GIFT FROM SHEILA HARRIS #860304 50.00 BALANCE AFTER THESE TRANSACTIONS > STATE CORRECTIONAL INSTITUTION AT ROCKVIEW BOX A BELLEFONTE, PA 16823 BALANCE ON ACCOUNT ON FEBRUARY 23, 2006, IS $ 48.26 i7 J " -, ", " FEBRUARY 23, 2006 EARL E. WALKER, CLERICAL SUPERVISOR 2 - INMATE ACCOUNTS 7.11 2.91 2.31 -1.74 48.26 48.26 PA DEPT. OF CORRECTIONS BUREAU OF COMPUTER SERVICES REMOTE. PRINT TIME 12:16 INMATE NAME NUMBER LAST PT7263 PEW T.NMATE ACCOUNTS SYSTEM PARTIAL ACCOUNT LISTING FROM PURGE FILE FIRST Mi ALFONSO RUN IAS365 DATE 2/23/2006 PAGE 3 BATCH DATE TRANSACTION BALANCE AFTER # MO DY YEAR TRANSACTION DESCRIPTION AMOUNT TRANSA CTION 3338 09-15-2005 14 MISCELLANEOUS REFUND AUGUST CABLE/TR SCIW 15.25 15 .45 3338 09-15-2005 34 RADIO/TV FYT CABLE TV - SEPTEMBER -15.25 .20 3397 09-16-2005 37 POSTAGE 9/15/05 -.83 - .63 3425 09-22-2005 37 POSTAGE 9/20/05 2 X _60 -1.20 -1 .83 3425 09-22-2005 37 POSTAGE 9/20/05 -1.42 -3 .25 3425 09-22-2005 37 POSTAGE 9/20/05 -2.44 -5 .69 3425 09-22-2005 37 POSTAGE 9/22/05 -.83 -6 .52 3425 09-22-2005 37 POSTAGE 9/22/05 2 X .60 -1.20 -7 .72 3425 09-23-2005 37 POSTAGE 9/22/05 6 X .37 -2.22 -9 .94 8272 09-29-2005 34 FYT CABLE TV FOR 9/29/2005 -15.25 -25 .19 BALANCE AFTER THESE TRANSAC TIONS ------ > -25 .19 PA DEPT _ OF CORRECTIONS INMATE ACCOUNTS SYSTEM RUN IAS36.5 BUREAU OF COMPUTER SE RVICES PARTIAL ACCOUNT LISTING DATE 2/23/2006 REMOTE PRINT TIME. 12: 16 FROM PURGE FILE PAGE 2 INM ATE NAME NUM BER LAST FIRST MI BT7 263 PEW ALFONSO BATCH DATE TRANSA CTION BALANCE AFTER # MO DY YEAR TRANSACTION DESCRIPTION AMO UNT TRANSACTION 3631 11-09-2005 36 PRINTED MATERIALS A_B.C.F. -5 .00 11.89 3631 11-09-2005 36 PRINTED MATERIALS SPEAR & SHIELD PUBLICATIONS -6 .00 5.89 3624 11-10-2005 37 POSTAGE 11/7/05 - .37 5.52 3645 I1-15-2005 36 PRINTED MATERIALS HUMAN RIGHTS COALITION -5 .00 .52 3641 11-15-2005 37 POSTAGE 11/07/05 2 X .60 -1 .20 -.68 3641 11-15-2005 37 POSTAGE 11/13/05 -8 .80 -9.48 3641 11-15-2005 37 POSTAGE 11/07/05 2 X .37 - .74 -10.22 8326 11-22-2005 34 FYT CABLE TV FOR 11/22/2005 -15 .25 -25.47 9335 12-01-2005 10 INMATE EMPLOYMENT FYT PAYROLL 2005 - 11 GRP 1 13 .68 -11.79 3687 12-02-2005 37 POSTAGE 12/01/05 - .37 -12.16 3712 12-05-2005 37 POSTAGE 12/05/05 4 X .37 -1 .48 -13.64 3712 12-08-2005 37 POSTAGE 12/06/05 -1 .29 -14.93 3736 12-12-2005 37 POSTAGE 12/8/05 - .37 -15.30 9346 12-12-2005 10 INMATE EMPLOYMENT FYT PAYROLL 2005 - 12 GRP 1 5 .76 -9.54 3736 12-14-2005 37 POSTAGE 12/11/05 - .60 -10.14 3736 12-14-2005 37 POSTAGE 12/11/05 -1 .06 -11.20 3736 12-14-2005 37 POSTAGE 12/11/05 2 X .37 - .74 -11.94 3682 12-19-2005 14 MISCELLANEOUS REFUND DEC CABLE TV/TRANSFER 15 .25 3.31 0 12-19-2005 82 TRANSFER OUT FAYETTE 0 12-19-2005 81 TRANSFER IN SMITHFIELD 7084 12-22-2005 37 POSTAGE PROCESSED WEEK OF 12/22/05 - .60 2.71 7111 12-29-2005 13 PERSONAL GIFT FROM HARRIS H739095 50 .00 52.71 PA DEPT. OF CORRECTIONS INMATE ACCOUNTS SYSTEM BUREAU OF COMPUTER. SERVICES PARTIAL ACCOUNT LTSTING REMOTE PRINT TIME 12:16 FROM PURGE FILE INMATF. NAME NUMBER LAST FIRST MI BT7263 PEW ALFONSO RUN TAS365 DATE 2/23/2006 PAGE 3 BATCH DATE TRANSACTION BALANCE AFTER TRANSACTION DESCRIPTION AMOUNT TRANSACTION # MO UY YEAR 7111 12-29-2005 13 PERSONAL GIFT FROM PEW H739092 50.00 8363 12-29-2005 32 SMI COMMISSARY FOR 12/30/2005 -1.91 BALANCE AFTER THESE TRANSACTIONS ------ I 102.71 100.80 100.80 PA DEPT. OF CORRECTIONS INMATE ACCOUNTS SYSTEM RUN IAS365 BUREAU OF COMPUTER SERVICES PARTIAL ACCOUNT LISTING DATE 212'12005 REMOTE PRINT TIME 12:16 FROM ACTIVE FILE PAGE: 1 INMATE NAME; NUMBER LAST FIRST MI STARTING BALANCE 9T7263 PEW ALFONSO 100-80 BATCH DATE TRANSACTION BALANCE AFTER # MO DY YEAR TRANSA CTION DESCRIPTION AMOUNT TRANSACTION 7145 01-04-2006 41 MEDICAL MED COPAY FOR WK END 12/31/05 8004 01-04-2006 32 SMI COMMISSARY FOR 1/04/2006 7176 01-10-2006 37 POSTAGE WKS ENDING 1/7-1/14 01-10-2006 37 POSTAGE WKS ENDING 1/7-1/14 01-10-2006 37 POSTAGE WKS ENDING 1/7-1/14 01-10-2006 37 POSTAGE WKS ENDING 1/7-1/14 01-11-2006 38 INSIDE PURCHASES LIBRARY COPIES 12/29-2_/7/06 01-11-2006 41 MEDICAL CO PAY WK ENDING 01/07/06 01-11-2006 37 POSTAGE POSTAGE WK ENDINGOI/14/06 01-12-2006 32 SMI COMMISSARY FOR 1/12/2006 01-13-2006 36 PRINTED MATERIALS BOOKS THROUGH BARS 01-17-2006 41 MEDICAL CO PAY FOR WK ENDING 01/14/06 01-19-2006 32 SMI COMMISSARY FOR 1/19/2006 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-23-2006 37 POSTAGE WEEK OF 1/23/06 01-26-2006 32 SMI COMMISSARY FOR 1/26/2006 -4.00 -12.83 -1.06 -.63 -.63 -.50 -6.00 -.63 -5.84 -3.00 -8.00 -3.73 -.63 -5.36 -4.64 -.87 -.63 -.87 -.87 -1.11 -9.43 96.80 83.97 82.91 82.28 81.17 80.54 80.04 72.04 71.41 65.57 62.57 54.57 50.64 50.21 44.85 40.21 39.34 38.71 37.84 36.97 35.86 26.43 PA DEPT. OF CORRECTIONS BUREAU OF COMPUTER SERVICES REMOTE PRINT TIME 12:16 INMATE NAME NUMBER LAST HT'7263 PEW INMATE ACCOUNTS SYSTEM PAR'T'IAL ACCOUNT LISPING FROM ACTIVE FILE FIRST MI ALFONSO BATCH DATE # NO DY YEAR TRANSACTION DESCRIPTION 7309 01-31-2006 38 INSIDE PURCHASES LIBRARY COPIES WK END 1/28-31 7309 01-31-2006 38 INSIDE PURCHASES LIBRARY COPIES WK END 1/28-31 0 01-31-2006 82 TRANSFER OUT SMITHFIELD O 01-31-2006 81 TRANSFER IN FAYETTE 3901 02-01-2006 37 POSTAGE 1/25/06 0 02-01-2006 82 TRANSFER OUT FAYETTE 0 02-01-2006 81 TRANSFER IN SMITHFIELD 7316 02-01-2006 37 POSTAGE POSTAGE 1/27/06 LEGAL 7316 02-01-2006 37 POSTAGE POSTAGE 1/24/06 7319 02-02-2006 13 PERSONAL GIFT FROM S HARRIS H725984 7318 02-02-2006 37 POSTAGE WEEK ENDING 02/04/06 7318 02-02-2006 37 POSTAGE WEEK ENDING 02/04/06 7318 02-02-2006 37 POSTAGE WEEK ENDING 02/04/06 7335 02-06-2006 30 PERSONAL GIFT TO THOMAS MERTON CENTER 7342 02-07-2006 37 POSTAGE WKS ENDING 02/04-02/11 7344 02-08-2006 38 INSIDE PURCHASES LIBRARY COPIES 1/31-2/11/06 8040 02-09-2006 32 SMI COMMISSARY FOR 2/09/2006 7369 02-13-2006 45 MISCELLANEOUS JULIANA YEBOAH 7375 02-14-2006 37 POSTAGE POSTAGE WK ENDING 02/1/06 7374 02-14-2006 38 INSIDE PURCHASES LIBRARY COPIES WK END 02/18/06 7378 02-14-2006 37 POSTAGE WEEK ENDING 02/18/06 7378 02-14-2006 37 POSTAGE WEEK ENDING 02/18/06 RUN IAS365 DATE 2,/23/2006 PAGE 2 TRANSACTION BALANCE AFTER AMOUNT 'T'RANSACTION -.60 25.83 -.10 25.73 -9.96 15.77 -.87 14.90 -.63 14.27 20.00 34.27 -.87 33.40 - .87 32-53 -1 .11 31.42 -5 .00 26.42 - .39 26.03 - .30 25.73 -3 .60 22.13 -5 .00 17.13 - .87 16.26 -3 .90 12.36 -1 .59 10.77 -1 .59 9.18 `. '? -- ALFONSO PERCY PEW, IN THE COURT OF COMMON PLEAS OF PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. EDWARD G. RENDELL, ET AL. DEFENDANT 06-1299 CIVIL TERM ORDER OF COURT AND NOW, this W_ day of March, 2006, pursuant to 42 Pa.C.S. §§ 6601- 6608. IT IS ORDERED that before a determination is made of whether to allow plaintiff to proceed in forma pauperis, he shall file of record a statement listing every civil suit he has instituted while a prisoner in any state and federal court with the docket numbers, and set forth either the disposition and the reasons thereof, or the status of such litigation. Alfonso Percy Pew, #BT7263, Pro se SCI Smithfield Huntingdon, PA 16652-0999 :sal 4 \ 1? ?. ., _, ,, .i,-)Aco"V-t 6T l clw,jOk,.. Pf f-At; 04, 1.ur,^ OER61'14 l hkj?"560 V?ecx Qw P(t,L ? C.v?` ? c ?f? `?d'!L7 ?\VC\ 5 sz ?? QLh L't->?CSE 4a.A_?4?L1prsC'• CS?? i C CIA, h cl Cad ?C? ?cS?¢ ???n? cis Cc ??c Ift Wl?.c L CCIL) -k\w-.?.e????t-?C -.-??Z;.,? -N--?c?arC?^u? ?•tic?, N?? L?????jCZ?r??t"k ?.?.C c?2?? . ??) Yt \v K>??1[_ , E2:?Ct?ct C,? £ CC c? 'l C'C,ct( WAQ> !?? > --4'--?le_n,\??? _ C_.c-'c• ..'cCC' _ v Lc, C.t ux-c CA Q'S •. tv pct) '??W '`!_ ?C'>NN l.?- ? Cn:i -?•? ??? 5? t?'?S?k'\CT ??? ?CrJ?C. CkC3'c CGr?SOCc ?2,'Lel 2,CL h\S (aCC v _. ?, v ?;''-lc??C'? C_, ICJ ('.\ C L"> eV C? 1`?-) O ?. >r. C?_C'l . AC{ Cc, L?'- cxJ A ` . MC E'i't. v,!,- ? r v?I v, 1?'i ?ti' r-C?C-t2Cr.,S , e-t?;cv_C t?? C ?cL 3C.CC?v CF? l w v ?? a'_ ? C_`??--? ?4yc,?.?_ L`-7 ;?1?{ ?• ?-?_tP?; ?C??nr?Cv?C'21? ?7c?1'?"?'_ hC 1 Ct2??_t?? 77,:Z ?U?ra C_?CI\l lC" Ctvi'lZ YU47 ??7E ?? (71- . ?l?_ ( T C Mpr^ c t7 1 1 1?-- ?? -1-I ZKIIQ j ) t,j -U-N-A C-, C- G? ?\ 1. -4z ti. l ?,,--- - - ,mott 4< 4 -• 2?1Crc- - M ( 1 c 1 j ??" J I\ K1 _ ALFONSO PERCY PEW, IN THE COURT OF COMMON PLEAS OF PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. EDWARD G. RENDELL, ET AL. DEFENDANT 06-1299 CIVIL TERM ORDER OF COURT AND NOW, this ?AS ?- day of April, 2006, the petition of plaintiff to proceed in forma pauperis, IS DENIED.' Ifonso Percy Pew, #BT7263, Pro se SCI Smithfield Huntingdon, PA 16652-0999 N sal v By the. Court, Edgar B. Bayley, 'Petitioner, who has filed seven other civil suits in this court, has now filed a twenty- eight page handwritten complaint under a heading "Suit In Equity Tort Law," alleging incidents while a prisoner under the jurisdiction of the Pennsylvania Department of Corrections. Among the twenty-two defendants are the Governor and a Senator on the Judiciary Committee. The relief he seeks is "Declaratory Judgment Injunctive Prospective Court Order." We will not allow him to again proceed in forma pauperis on such a suit. '?? : .__ ,, ___ ,: - ?_; ,,.. , ?::? . Curtis R. Long Prothonotary efftce of the protbonotarp Cumberfanb Countp Renee K. Simpson Deputy Prothonotary John E. Slike Solicitor (?1? --z 3 9 CVIL TERM ORDER OF TERMINATION OF COURT CASES AND NOW THIS 28TH DAY OF OCTOBER, 2009, AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R C P 230.2. BY THE COURT, CURTIS R. LONG PROTHONOTARY One Courthouse Square • Carlisle, Pennsylvania 17013 • (717) 240-6195 • Fax (717) 240-6573