Free Motion for Preliminary Injunction - District Court of Arizona - Arizona

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’ ARIZONA DEPARTMENT OF COR I ` NS ·‘‘ i n' . .
. i 1 ~,= Expiration Date
' Dutylspecial Needs Order - Inmate at ‘ i ,,;;i‘? - [Q {Z
v' Check the Appropriate Category
i - - _ La _inifQ“gri_tined to living quarters with
U Fu" °““’ __ »—~»iEi»¤alimm pr.-rie.;,—t—s—~
ENSURE ALL LIMITATIONS ARE COMPATIBLE
Inmate Limited Duty rrcneck only these that apply) Other Limitations of Daily Activity (ucimk mryrneeyifereppm
/'/-V = : X:
E No ming. No pushing, NU pulling. No Yes Inmate is able to No Inmate is unable to
, E Yes E No Meals in Living Quarters
C] No lifting over 10 20 ______ pounds
U Yes Q No Atterid·SohoolsJPrograms
N t'ti bd' tw't'i .‘
I:] 0Br§§;;);: Bn mg] I;] Yes E No : ,,FieId Activities _____ day(s)!week(s)
Q No repetitive motion to/irliiured part U YBS Q HW" Walk TFBGK {A
M ‘ ¤_
B°dY pa" Q Yes fi] No Sports Activities day(s)!week(s)
Q No work reachingabove the shoulder YES,/' E No Visitation
A· :2*
Q No operatiorifof a motor vehicle C}/Yes Q NO Other {
Q No climbing} ladders ,--- stairs *
[ii No operation of machinery or power tools?. nlln U M X ff ‘‘"`" M irxnmm `A’I “ “ 4- ffr , {1 _A _
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N QH i rk ' ts ,f» »».,Q_ `·' i wi I ,
[1 -comp ex wo assignmen E g _``=g L; Qin i n 6,/ { E if
E Exposure to direct sunlight only with h&t,$1.tf`l$CfBEI‘I, E Rig __,a A .,;= J; { { _ A
r"°"¤S'¤°*° 5***** ¤*°· ’ K .»’ »r ,4 .,-~
I] $',2£§B.i’§,‘;T2r£3 ""’*"“""’*°"’ 'f5""’"‘° "‘{?‘°"°"i""°""""*ii"" i ‘ {
’» .*4 ‘ t g}_:’ `j`;i`i` E R
Work Capacity, Specify Limitations; (Circle incurs/eayar Additienal Considerations ,;.¢ it
C { WM.-IAM 5 `"'VAM - J!} V ‘i._"` "‘¤gm_M_w~/._M,»" /:4
E U ""°“°?¥ °a°°°"‘f it E ·.s
I _ Can sit oursiday or consecutive hours Medlcal Property Issued - /x/·
Can stand hours/day or consecutive hours ,,»~”
Can w hours/day or consecutive hours //,./'!
C] er LimitationslConsideratlons (Exmwh} M¤di¤ to be Retumed to Clinic by: L
E Providers Name N MD. Providers Title
¤¤- E ““%t"ar¤ mi
DEA BA G0
Provider Signature _ X Date
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.’ rgflj V ’. » /4/(·‘ /L» ,i ·*‘ £5°*~—
” ma =- 's Signal re I Date
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` f'·n. · ·'/
" 'C ·: y ' J t
_ Inmate Name (Last, Hmm.; ADC Number
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M? Lrfiu, .4 A ,2.,2 x 2 2 {
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oemuum Case 2:O4—cv-OO446—JAT Document 2 ` ze e e 2,- if : - : ..-.·
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* ARIZONA DEPARTMENT OF CORFtP"'*lQONS Da~ _u9d . Expiration Date
i - ‘- M. I l· I
‘ Dutylspecial Needs Order - Inmate Health " '2 I 05 3 If ·
1 '•·
V Check the Appropriate Category "

{ ENSURE ALL LIMITATIONS ARE COMPATIBLE
Inmate Limited Duty lvcneek only those mareppry) • ther Limitations of Daily Activity rw Check only mcse that app
lj No |mmgQ No pushmg NG pumng NO running E|Yes = Ingte Is able to No = Inmate is u le to
· _ ‘ No Meals in Living Quarte
C] No lifting over 10 20 50 pounds
[I Yes Q No Attend Schools! grams
I N ‘ d' tw` t'
3 bm mg! .5 mg Q Yes Q iv ; » Field · · · es dayis)/weekisl
ij No repetitive motion to injured art ij Yes III N6 I ‘·‘·• TI’¤¤k R
B°dy Pan ij Yes Ii] No SportsA l · ‘ties_wday{s)/week(s)
Q No work reaching abov the shoulder 1] Yes E No Visitatiun
Q;] No operation of a otor vehicle I as Q NO Other
Q Q No climbing ladders __ stairs A
E .. . .,.. use I
i E No oper on of machinery or power tools Q ```‘ Q I ~ " {
§ E Neo -0ompIexwork assignments Q' Q , QQ , i L I t
S . . . — I · " .‘ ~· ·
ure todrect sunll ht only wth hat, sunscreen, l· ‘ 4 I .· _;_ 4,.
if Q nlgugleeve shirt, etc. Q it ; i I Q p_ Qi Q I . I g s`f¢r°*" “ "°"
i No exposure to respiratory irritants re.g.Q¤nem:¤eIs, paints. * ·' *”i**$·iii ii*!
§ grass cuttings, etc.) Q Q my.<;.;;T¢i.»;·i;i»e»i,t_ _
{ Work Capacity, Specify Limitations: {cl.-cle eimerheurs/deyer Q. Additional Considerations ,·‘`'
E consecutivehours) " Q_ ZQQ I" 5 Q - ~ Q_ _Q "~~ ..l, W,. `
I ¤"*d¤Y C¤¤°°“Y T;} ‘i`t , » L. “` I n .
Can stand ;§1rslday or consecutive hours
Q Can walk rslday or consecutive hours ;_
i CI Other Lim“au°“slC°"Sid°rati°"s '"J Q Medical Pr erty to be Retumed to Clinic by:
I Pm-were Name R. E. VINLUAN, M.D. ? at greyiuewxnle
Q DEA BA 6086020 214 · `
Q ·; -5.*:. Q. wb- H:
Pr? agnaiure " JN pale ` I
I i w 3-/az;
L Inmate‘s Signature t h ‘ j ’ Date
· ,,LJQ 1_ B-?- ,
T _ Inmate Name {Lea, Frmui) ADC Number
T F p I A A E De\eo<·» Pllleet-k -- as - Z59.TsJ=l
‘ Date of Blrlh Faclliqlunit
‘ . M ·· · • - · I ` _
nimnum Case 2:O4—cv-OO446#JAT Document · ·: : 59 = ; : · *a
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* ARIZONA i‘¤?,_;, y e Racrious "_ jg;
Health Nee · gg;
(Use For Nen-Emergency Requests Only}
IDENTIFICATION · n` - E
¢:
Inmate Name {Las:. Faster:.} ADC Number Date
- ,l Lew - ._ 2 Y Li I za e5 ,
g CellIBed Number Unit P.O. Box lnstitutig;lFa Iity
'6 — —I . : 0 . ec aeuziw L _
g You are required to be truthful. Failure to be cooperative and any abuse of the health care system or its staff
could cause a delay in delivery of care to you and others, and may result in disciplinary action. Use this form to
describe one issue only! I
AREA OF INTEREST (cheek only one meek below " . .
E Medical lj Dental Cl Pharmacy C] Mental Health Q Eyes I] FHA El Other (speedy) _
PLEASE PRINT! Describe your medlcalldental treatment issue need in the space below. Be clear and specific.
NO ADDED paces.: I-me Besv ce·¤‘¤‘¤F·e¤ MM- M $sS.si~¢a HITS. se ¤<-T·¤F °‘¤- 17****6
PEM I-{EAR? 5e9c,;gy_y i-lnué' biew s¤6mH‘?r·•~l6' l·I,r~¤·2 3 ngpu£.,q»,,.,_;.; pm my {pp; ,¢w0 ¤A’T#‘f¤»
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B1 gap;. gusto;} YTAIQF ANP MEJIZ/IL BEOIA//IN - ‘ B °‘r &E”‘-*6 (WHNEU Tb A wtit-ELC!/Arr? ·
I understand that, per ARS 31 -201.01, I will be charged a $3.00 Health Service fee (excluding exemptlcihs granreu by
statute) for the visit that tam herein requesting. I further understand that by paying this fee I do. not have the night
to dictate treatment or who provides treatment. _
Inmate's Signature
/
T ijlr- l. -· y; amt *
REMOVE THE ‘ `i LDENROD COPY AND PLACE THE REMAINDER IN THE DROP BOX -
REFERRAL BY MEDICAL STAFF L ,
I;] Medical [Il Dental E Pharmacy I;] Mental Health I] Eyes lj FHA I;] Other gspacrryi
E. Comments
2 .
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(D j A 3,
Staff Signature be Date · ‘ - Time
A ‘ PLAN OF ACTION E · »- -
2 _ I , ( _ H A ..
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@1 Staff Signature ·ime = ..
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1 uatrieuuen; vlnr -l tfzilé-Cv;OO446-JAT Documen 179-2 Filed 11/O7/200 Page 3 0f 3 “°"‘°'°
Canary, Plnk&Goldenrod-Inmate "; I y THTIBT
7 .

Case 2:04-cv-00446-JAT

Document 179-2

Filed 11/07/2005

Page 1 of 3

Case 2:04-cv-00446-JAT

Document 179-2

Filed 11/07/2005

Page 2 of 3

Case 2:04-cv-00446-JAT

Document 179-2

Filed 11/07/2005

Page 3 of 3