7

Case 7:23-cv-00572-RSB-PMS Document 1-1 Filed 09/05/23 Page 1 of 5 Pageid#: 4

NORTHWESTERN REGIONAL ADULT DETENTION CENTER INMATE GRIEVANCE FORM
RESPONSE/REASON: MR YAIE'S YOU ARE CORRECT IN SAYING THE SHOE WE PROVIDE IN NOT FOR
PLAYING BASKETBALL. THE CROC STYLE SHOE IS A SHOWER SHOE AND A LOUNGING SHOE. WE
NEVER STATED YOU COULD PLAY BASKETBOL IN THEM. YOU HAD THE OPFIEN TO PURCHASE AN
ATHLETIC SHOE FROM COMMISARY. YOU MADE THE
WHOILE TO WEAR THE CROG STYLE SHOE TO PLAY BOLL IN. SO WITH YOU MAKING THAT
DESSESON SIIR THE RESPONSIBILITY FALLS ON YOU.
my DEGBEON WILL BE THIS GRIEVANCE IS UNFOUNDED.
Officer signature and unit number: ++JAR= 55#
Date: 7-18-23
Completed response received by Officer, copy given to inmate, and original
forwarded to Administrative Services.
Officer's Signature:
Ashucal #219
Date:
7/20/23
Division Command Review: Capo Heath ListsDate: 7-20-23
Founded/Unfounded
DC60
pg.2
1
Case 7:23-cv-00572-RSB-PMS Document 1-1 Filed 09/05/23 Page 2 of 5 Pageid#: 5
NORTHWESTERN REGIONAL ADULT DETENTION CENTER INMATE GRIEVANCE FORM
Inmate Last Name, First Name, MI: Yotes Kilviv Deov
Housing Unit: 00-5
Grievance number assigned by Administrative Services:
G2023-0713-042
Please read "Inmate Grievance Procedure" In the Inmate Handbook prior to completing
this form. Forms will not be accepted unless you have attempted to personally
resolve your concerns with the Pod Officer. Pod Officers will only accept grievance
forms that are complete and written within the space provided, legible, and signed
by Inmate. A copy of the answered Request Form must accompany the grievance form.
Additional attachments will not be accepted. Use of the grievance procedure will
not be held against you.
I have tried to resolve this matter with Officer/Employee:
In:
Legibly state your grievance here:
The cross That was Issued To Me ON 4/5/23
To shower and walk around IN pod and
for Recoration, The cross are Not qualified for
Recoation, You can see, Due TO The Incidentou ON April 14th of 2023, During a game
of Horse I Broke My left leg causing Me to Receive a
Metal plate and serrais In My left aukle and I Tore legiments IN My left Knee where
I Had To get Three scrents IN My left Kver also
Inmate's Signature: 253
Received by:
Bain #70
DC60
Date :
7/13/23
Date:
7/13/23
pg.1
Case 7:23-cv-00572-RSB-PMS Document 1-1 Filed 09/05/23 Page 3 of 5 Pageid#: 6
NORTHWESTERN REGIONAL ADULT DETENTION CENTER INMATE GRIEVANCE APPEAL FORM
Inmate Last Name, First Name, MI: Yates, Kelvin, Deov
Grievance number from initial complaint:
G2023-0713-042
Housing Unit: CC-5
Pod Officers will only accept grievance appeal forms that are complete and written
within the space provided, legible, and signed. Additional attachments will not be
accepted.
Appeal of grievance received by Officer!
1.Stewart 196
Date: 8/4/23
I am not satisfied with the response to my
grievance because : I am Appealing -The Decision of My.
SENMote_ Grievance, Form, That I streter ou
The cone style shoes
Inmate's Signature:
Date: 8/4/23
Forw
Super Corbin/Capt-Custer Date: 8/4/23
DC61
pg.1
Case 7:23-cv-00572-RSB-PMS Document 1-1 Filed 09/05/23 Page 4 of 5 Pageid#: 7
NORTHWESTERN REGIONAL ADULT DETENTION CENTER INMATE GRIEVANCE FORM
SUPERVISOR'S
RESPONSE/REASON:
Mr. Yates
The shoes you were given upon intake were given for showering and walking, Not
sports. You can purchase a set of shoes from canteen for any recreation.
Supervisor's Signature:
Capo H. Custar
Date: 8-11-23
Completed response received by Officer, copy given to inmate, and original
forwarded to Administrative Services.
Officer's Signature:
SBain
Date:
8/11/23
Division Command Review: Sist Carleo
Date: 08/11/23 Founded Unfounded
DC61
pg.2
Case 7:23-cv-00572-RSB-PMS Document 1-1 Filed 09/05/23 Page 5 of 5 Pageid#: 8
NORTHWESTERN REGIONAL ADULT DETENTION CENTER INMATE REQUEST FORM
NAME KalVIN Yates DATE 6/23/23 IOUSING CC-5
INSTRUCTIONS: Please check the problem or request area. Be specific about what
action you want. This is not a grievance form.
Appeal of Discipline
Mental Health
Canteen/Inmate Accounts
Notary
Classification/Housing Assignment
Program Activity
Food Service
Property Bin No.
Inmate Work Force
Records
Laundry
Request for Grievance
Medical
Work Release
Other, Specify
Request: This Is My Second Request IN Crocs THE Sus =null 50
He ou 4/5/23 are vot
qualified s Sur recréation. You can
Su DueTO MY Incidenton 4/14/23
Received
197
Date: 6.23.23
Action Taken: FWD via C.O.C.
Received ast H. Custa
By:
Date:
Final Disposition: Issue a grievance
Signature:
H. Curo
Date
7-5-23
Original (White) - Completed form scanned to Inmate File. Copy 1 [Yellow) -
Completed form returned to Inmate with Action Noted. Copy 2 (Pink) - Retained by
Inmate at Time of Request.
OC7 fev 10/29/20