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Grievance #:
OFFENDER
Date Received:
S 1 JtLF 1 GRIEVANCE FORM
Date Due:
Grievance Code:
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Unit: {_^A-y ' " » O Extension Date:
Unit where incident occurred: CaxA^iaa "SCcf-H" Date Retd to Offender:
You must try to resolve your problem with a staff member before you submit a formal complaint. The only exception is when
appealing the results of a disciplinary hearing. / » 0 / / _ /• <"~
•Who did you talk to (name, title)? ",0 f!AfyO ' K/>ofl*-?<•* «/u„„o
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What action was taken? tAjft^-
State your grievance in the space provided. Please state who, what, when, where and the disciplinary case number if appropriate
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1-127 Front (Revised 11 -2010) YOUR SIGNATURE IS REQUIRED ON BACK OF THIS FORM (OVER)
Appendix F
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