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Grievance #:
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1-127 front (Revised 11-2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM (OVER)
Appendix F
OFFICE USE ONLY
Texas Department of Criminal Justice Grievance #:
UGI Reed Date:
STEP 2 OFFENDER HQ Reed Date:.
GRIEVANCE FORM
Date Due:
Offender Name:. TDCJ#JMM. Grievance Code:.
Unit: %MftJDV\^V Housing Assignment: C-~ \ 'b —?J~> -"f? Investigator DD#:.
Unit where incident occurred: KlfvLlX Un> yr Extension Date: _
You must attach the completed Step 1 Grievance that has been signed by the Warden for your Step 2 appeal to be
accepted. You may not appeal to Step 2 witha Step 1 that has been returnedunprocessed.
Give reason for appeal (Be Specific). / am dissatisfiedwith the response at Step 1 because...
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1-128 Front (Revised 11-2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM (OVER)
Appendix G
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. 02-.APR 2015 -PW SI: ^'""^—
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CHRISTOPHER A. PRINE
CLERK.
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Offender Signature : VO Date: Crtfo^flUS
Grievance Response:
Signature Authority:
Returned because: *Resubmit this form when corrections are made. OFFICE USE ONLY
Initial Submission CGO Initials:.
LJ 1. Grievable time period has expired. DateUGIRecd:
LJ 2. Illegible/Incomprehensible.* Date CGO Reed:
(check one) Screened Improperly Submitted
LJ 3. Originals not submitted. *
Comments:
LJ 4. Inappropriate/Excessive attachments.*
Date Returned to Offender
LJ 5. Malicious use of vulgar, indecent, or physically threatening language. 2"1 Submission CGO Initials:
DateUGIRecd:
LJ 6. Inappropriate.*
Date CGO Reed:
(checkone) Screened Improperly Submitted
Comments:
CGO Staff Signature: Date Returned to Offender:
3d1 Submission CGO Initials:
DateUGIRecd:
Date CGO Reed:
(checkone) Screened Improperly Submitted
Comments:
Date Returned to Offender:
1-128 Back (Revised 11-2010) Appendix G
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Action Requested to resolve your Complaint,
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Offender Signature: YO-MXK ggjnjg^
Grievance Response:
Signature Authority: , Date:
If you are dissatisfied with the Step 1 response,you may submit a Step 2 (1-128) to the Unit GrievanceInvestigator within 15 days from the date of the Step 1 response.
State the reason for appeal on the Step 2 Form.
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Returned because: *Resubmit this form when the corrections are made.
[~11. Grievable time period has expired.
I~l 2. Submission in excess of 1 every7 days. * OFFICE USE ONLY
Initial Submission UGI Initials:
Q 3. Originals not submitted. *
Grievance #: .
I 14. Inappropriate/Excessive attachments, *
Screening Criteria Used: _
|~1 5. No documented attemptat informal resolution. *
Date Reed from Offender:
n 6. No requested reliefis stated. *
Date Returned to Offender:
n 7. Malicious use of vulgar, indecent, or physically threatening language. *
l^SHbjnissifia UGI Initials:.
T~l 8. The issue presented is not grievable. Grievance #: . -
f~l 9. Redundant, Referto grievance # Screening Criteria Used:
l~l 10. Illegible/Incomprehensible. * Date Reed from Offender:
C] 11. Inappropriate. * Date Returned to Offender:
UGI Printed Name/Signature: - S^ubmission UGI Initials:.
Grievance #:
Application of the screening criteria for this grievance is not expected to adversely Screening Criteria Used:
Affect the offender's health.
Date Reed from Offender: _
Medical Signature Authority: Date Returned to Offender:
1-127 Back (Revised 11-2010)
Appendix F
Weylin Alford v. State
Combined Opinion