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I;] Contiqentlal information . Reliability ’ · _
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· 1 I;] Use ot force report I;] Other (epeclfy)
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I] Wltnese exclusion Name _ · _ - Reason · ~.....
Physical evidence, written testimony:
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[Basis fortindtng: - · . .. l- l t e _ ` _
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igasls for sanctions: U t. ` _
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Dlsctpllnary ooordlnatorslgnature ‘ ` Date _ _ °
- lnvestlgator slgnature _ Date
’ You may appeal a fin g of guilty by a hearing offlcer within 15 days,
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- Copies (5):lnvestlgetor, reporting employee, Inmate, dlsciplinery tile. and inmate masterflle — g
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