Free Statement - District Court of Arizona - Arizona

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Exhrbnt N_
Case 2:04-cv—OO323-FJIVI Document 70-17 F¤Ied10/13/2005 Page10f2

ARIZONA DEPARTMENT OF CORP “IONS
Protective Segregation Assessment . l o A `
iemete Name {Lash Fh,e`M_,_) o V ADC Number Location! Unit l "
t nj ° /0 H? ev _
RSSB ' · Age ` A
m ‘ G I
ClassiH§tion Scores " YZ - l `
P I A M NIH E V AID S
Score Comments _
STG Affiliation Validation ` Sex Offender ` I
. Li · I;] Suspect Cl Pending lj Validated · s E No ·
Release Dates ‘ U ` Crime(s) _/Jp z»··p>·r /°*’—»'5'.¤-L ·f¤·#—-ele 40.9)
‘ ‘ . . ‘ J
` _ ig 77’¤Lz¢s»·¤5»····¤·=—- ma z,;o,eJ_£,2_Lr · ·
. 0 nl .
Previous PS ‘— ews Yes lj Ng l . .
‘Dete Outcome Date L/.4ZLT Outcome _
Date Outcome Date `Outeqrne ·
Date /'Z{;,gg Outcome `Da_te Outcome-_ -
Previous PS Placement . III Yes {J" IQNO i ."··»,\ .;;-1 i _e.?;,»’r I W""‘r~,;__ "
. . a 5 is ff `~.-."_`.; _ ,
When _.e.L....... tuitliere I
Nhen ··—·—····+··v%#wh-Bra Whale *···r·········*···
Victim of Assault l Yes y ` 0-·Q;;;-·-—:·»—··;_i{.;T Current lj l l
it _ . ._ _;. _» ff'-; ¥;32.fgif.;`=e;‘e, · ].»"`T-rg_f';?`iff ‘ ` l
l¤l\-IW ' - ·_No-,_.·-Y§·.__ §_·r;Q yj;tylii=ier“'f `. .··" l;i~.§eri¤us·i“‘~—`___®_’Medic T'·ratment
-2 · A- ·']· '- ' , I-J-_`--I l _ I . N-hen
Data `H @2%* ` Dat?=’/ -
_ Discipline History `(lt·Iej¤rs*h;?;rHgiIiiIrrt;:;threeteningresseufjréigsambttng;etc) ,·' /7*5 J 9-3;;; .¤ c¤v`;ao¤¤»s·¤j LFS: /4;e·_,,.,» , i
lp//F!/[pe 29554r · _ -
J . . ·
Current Reasonrfor review __ / · ' _
//"' ‘$2’>9;·5__g· 7'?=¤’ff»9-7·;2»..s_p ,5},- ,;__ ,-0,
l _ /27 [K//.»9;·..· /77 ..•¢'/ `
Is there any information toinvestigate'? _ Yes No
ls the inmate requesting a Housing Change Only'? · Yes No
_ is the inmate's issueisolated to current events? _ , `Yes No
Does the inmate have current DNHW's'? ‘ · - . l B YES- Ne
Does the inmate have Altemative Placement possibilities? yee Ne
Was the inrnateinterviewed bythe Deputy Warden or Designee'? I Il, Yee I Ne
Decision: Qt DIG? Protective Segregation Review Required [Il DIG? Protective Segregation Review Not Required
Rationale: eg { gu ` ` — A ‘
. is · _ ‘ · ‘ ·
’";L” »’Zf·*~¢~·=» av M; rc .4.-,- fa PJ55/fr r fz; é ·:t-.9)-L,
Deputy Warden I Administrators Signat re Date ° ·
/ i ase 2;04-ev-00s2s- ment O-17 , i I· 0/1 gigs Pege%%?Q°2
··-’ - ·•.A4.,.a.... .Q G J" ..
‘ aus-YP
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Case 2:04-cv-00323-FJM

Document 70-17

Filed 10/13/2005

Page 1 of 2

Case 2:04-cv-00323-FJM

Document 70-17

Filed 10/13/2005

Page 2 of 2