Free Answering Brief in Opposition - District Court of Delaware - Delaware

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DELAWARE DEPARTMENT OF CORRECTIONS
U REQUEST FOR MEDICAL/DENTAL SICK CALL SERVICES
FACILITY: M-Y-C-1· (GANDER H
This request is for (circle one): MEDICAL DE T MENTAL HEALTH

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Date of Birth SBI Number Date Submitted J
Complaint (What type of problem are you having) 1/r 5 F7L(‘°g/__;E€v-lj; j7L
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mate Signature Date - F
The below area is for medical use only. Please do not write any further
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Provider Signature and Title Date Time
3/I/99 DEOI n
Form# MED 263
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Case 1:06-cv-00011-SLR Document 67-4 Filed 08/25/2006 Page 2 of 4
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€RIEvANC5FORM
FACILITY: E I DATE; C2 (3/ /46 `Oé I
GRIEVANPS NAME: Afgwgd g_¢3_;{(¢5D SBI#: [@72 I [
CASE#: 2 U _ TIME OF INCIDENT: (ZN$QZj2E|?
HOUSING UNIT; K/
BRIEFLY STATE THE REASON FOR THIS GRIEVANCE. GIVE DATES AND NAMES OF OTHERS INVOLVED
IN THE INCIDENT OR ANY WIINESSES. - . '
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ACTION REQUESTED BY GRIEVANT; Q ZE é Eg [me ééfv AQ Q Q,u·I=·<&`
GRIEVANTS SIGNATURE- F DATE; lg {gf; 576
WAS AN INFORMAL RESOLUTION ACCEPTED? (YES) (NO)
(COMPLETE ONLY IF RESOLVED PRIOR TO HEARING)
GRIEVANTS SIGNATURE: DATE:
IF UNRESOLVED, YOU ARE ENTITLED TO A HEARING BY THE RESIDENT GRIEVANCE COMfMIT’I`EE.
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GRIEVANT
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l Inmate Grievance Office

Case 1:06-cv-00011-SLR Document 67-4 Filed 08/25/2006 Page 3 of 4
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iNMATE·s NAME; /\€0#“"9’?J ??‘¤*~j IU sB1#; IQQ Z EI
HOUSING UNIT: CASE #:
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SECTION #1 - U
DATE & TIME OF MEDICAL INCIDENT: { 2N' ig / l
TYPE OF MEDICAL PROBLEM: X _
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GRIEVANT’S SIGNATURE: (`J*·~·€»*l DATE: 2·· _b/ H3 6 Og
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ACTION REQUESTED BY GRIEVANT: f C7 €C€ 6 V f (Z»"I'gZ gg (
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DATE RECEIVED BY MEDICAL UNIT:
NOTE: EMERGENCY MEDICAL CONDITIONS WILL-TAKE PRIORITY. OTHERWISE, MEDICAL
GRIEVANCES WILL BE ADDRESSED AT THE WEEKLY MEDICAL COMMITTEE MEETING.

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A SMYRNA DE, 19977 EX réfl Ge.: 3
‘ Phone N0. 302-653-9251
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Offender Name : BA LI , LEONARD K SBl# : 001002Si Institution : DCC Q
;Grievance # Grievance Date Category : Individual l
I ?Status · Unresolved, Resolution Status : ` 0 RBSOI. Data Z ‘
Grievance Type: Health Issue (Medical) incident Date : ii/29/2005 Incident Time : 13:00 -
AGC : lvlerson, Lise lvl Housing Location : Bldg V, Tier D, Cell 1, Single .
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jilescription of Complaint: Inmate claims: After repeated attempts to see Dentist (l have trouble eating because of missing I
_, teeth) and after signing off on a grievance on 15 Nov(at gander hill) and after I was promised I
I , dental treatment, I was today refused treatment because of wrong information in Dental records. . g
J Remedy Requested : To receive proper Dental Treatment.
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I Medical Grievance : YES . Date Received by Medical Unit : Ot/11/2006 ‘ y
Investigation Sent : 01/1 1/2006 Investigation Sent To : lvlalaney, Christine ‘
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