Ward 113886 v. NaphCare Incorporated

• Court: District Court, D. Arizona
• Decided: January 16, 2025
• Docket: 2:24-cv-03676
• Status: Unknown

Opinion

1 JL 2 WO 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Calvin Clinton Ward, No. CV-24-03676-PHX-JAT (JZB) 10 Plaintiff, 11 v. ORDER 12 NaphCare Incorporated, 13 Defendant.

15 Plaintiff Calvin Clinton Ward, who is confined in the Arizona State Prison 16 Complex-Eyman, has filed a pro se civil rights Complaint pursuant to 42 U.S.C. 17 § 1983 (Doc. 1) and an Application to Proceed In Forma Pauperis (Doc. 2). The Court will 18 dismiss the Complaint with leave to amend. 19 I. Application to Proceed In Forma Pauperis and Filing Fee 20 The Court will grant Plaintiff’s Application to Proceed In Forma Pauperis. 28 21 U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. 22 § 1915(b)(1). The Court will assess an initial partial filing fee of $26.78. The remainder 23 of the fee will be collected monthly in payments of 20% of the previous month’s income 24 credited to Plaintiff’s trust account each time the amount in the account exceeds $10.00. 25 28 U.S.C. § 1915(b)(2). The Court will enter a separate Order requiring the appropriate 26 government agency to collect and forward the fees according to the statutory formula. 27 II. Statutory Screening of Prisoner Complaints 28 The Court is required to screen complaints brought by prisoners seeking relief 1 against a governmental entity or an officer or an employee of a governmental entity. 28 2 U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 3 has raised claims that are legally frivolous or malicious, that fail to state a claim upon which 4 relief may be granted, or that seek monetary relief from a defendant who is immune from 5 such relief. 28 U.S.C. § 1915A(b)(1)–(2). 6 A pleading must contain a “short and plain statement of the claim showing that the 7 pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 does 8 not demand detailed factual allegations, “it demands more than an unadorned, the- 9 defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 10 (2009). “Threadbare recitals of the elements of a cause of action, supported by mere 11 conclusory statements, do not suffice.” Id. 12 “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a 13 claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 14 550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual content 15 that allows the court to draw the reasonable inference that the defendant is liable for the 16 misconduct alleged.” Id. “Determining whether a complaint states a plausible claim for 17 relief [is] . . . a context-specific task that requires the reviewing court to draw on its judicial 18 experience and common sense.” Id. at 679. Thus, although a plaintiff’s specific factual 19 allegations may be consistent with a constitutional claim, a court must assess whether there 20 are other “more likely explanations” for a defendant’s conduct. Id. at 681. 21 But as the United States Court of Appeals for the Ninth Circuit has instructed, courts 22 must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 342 23 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less stringent 24 standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. Pardus, 551 25 U.S. 89, 94 (2007) (per curiam)). 26 If the Court determines that a pleading could be cured by the allegation of other 27 facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 28 of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). The 1 Court will dismiss Plaintiff’s Complaint for failure to state a claim, but because it may 2 possibly be amended to state a claim, the Court will dismiss it with leave to amend. 3 III. Complaint 4 In his single-count Complaint, Plaintiff names NaphCare Incorporated 5 (“NaphCare”) as the sole Defendant. Plaintiff asserts a claim regarding his medical care. 6 He seeks declaratory, injunctive, and compensatory relief, punitive damages, and his fees 7 and expenses for this case. 8 Plaintiff alleges the following: 9 On May 17, 2024, Plaintiff submitted a health needs request (HNR) stating he had 10 several masses on his stomach that were causing him extreme pain. On June 3, 2024, 11 Plaintiff submitted another HNR stating he had been waiting weeks to be seen about the 12 painful masses/lumps on his torso, that the “situation had gotten much worse,” and that 13 there was something “seriously wrong.” On June 12, 2024, Plaintiff submitted a third HNR 14 again stating that he had been waiting weeks to be seen for the painful masses that were all 15 over his torso. Plaintiff wrote that his pain was at an 8 out of 10 “all the time.” 16 On June 20, 2024, Plaintiff submitted an informal complaint against NaphCare. 17 Plaintiff stated that he had numerous masses on his torso that were causing him extreme 18 pain and that his pain was at an 8 out of 10 all the time. Plaintiff wrote that the pain was 19 affecting his “everyday life,” and it was “almost impossible to sleep.” Plaintiff stated that 20 the masses were “getting bigger fast” and asked that the informal complaint be treated as 21 an emergency request for medical care. Plaintiff did not receive a response to his informal 22 complaint. 23 On July 16, 2024, Plaintiff submitted a grievance against NaphCare, again stating 24 that he had masses growing all over his torso that were causing him extreme pain, that the 25 masses were getting bigger “really fast,” and that his pain was now at a 10 out of 10 every 26 day, even in his sleep. Plaintiff wrote that sleep was impossible, and his medical situation 27 was affecting his everyday life. Plaintiff asked that the grievance be treated as an 28 emergency request for medical care. On August 6, 2024, Plaintiff received a response to 1 his grievance stating that his informal complaint had been answered on July 12, 2024, that 2 Plaintiff was scheduled for an ultrasound and then to see a dermatologist, and that a 3 treatment plan would be determined based on the results of the test and the specialist visit. 4 On August 7, 2024, Plaintiff submitted a grievance appeal. Plaintiff explained “his 5 entire medical situation” and stated that he “was at a complete loss as to what to do because 6 he believed that it was ‘now clear’” that NaphCare “just did not care about him.” Plaintiff 7 wrote that he was experiencing very intense pain that had “made its way into his hernia,” 8 the upper right side of his leg, and into his right testicle, which was purple and bruised. 9 Plaintiff’s grievance appeal was denied. The response stated that an ultrasound had been 10 performed and that a treatment plan would be determined “by the results of the diagnostic 11 tests ordered.” 12 On August 24, 2024, Plaintiff submitted an HNR “begging for help. Plaintiff stated 13 he was in an “extreme amount of pain,” and that the pain had moved into his hernia, his 14 right testicle, and down his right leg. Plaintiff wrote that it hurt “just to breathe” and asked 15 that the HNR be treated as an emergency request for medical care. On September 28, 2024, 16 Plaintiff submitted an HNR stating that he was still in extreme pain, and the pain 17 medication he had been given had “done absolutely nothing to help” his pain. On October 18 3, 2024, Plaintiff submitted an HNR stating that his hernia and right testicle “hurt badly” 19 and that the medication he had been given had “not done anything” to help with his pain. 20 On October 27, 2024, Plaintiff submitted an HNR stating that he was in extreme 21 pain all the time and that the pain was shooting down into his right testicle and down both 22 his legs. Plaintiff “questioned why the ultrasound that had been conducted only showed 23 two of the six lesions that had been found” and asked what the treatment plan was “now 24 that a CT scan had finally been conducted.” On November 11, 2024, Plaintiff submitted 25 an HNR asking to see NaphCare provider Patricia J. Blanck-Miller to discuss the results of 26 the CT scan and to “figure out why her requests for surgery and for a visit with a 27 dermatologist had been cancelled.” According to Plaintiff, Blanck-Miller referred Plaintiff 28 to a radiologist, dermatologist, and urologist, and requested surgery for the removal of 1 Plaintiff’s lesions and “better pain medication,” but all her referrals and requests were 2 denied. Plaintiff has had blood tests, undergone an ultrasound and a CT scan, and been 3 given generic Tylenol for pain, but he has not been seen by any specialists “to figure out 4 what is going on with him medically,” and he has not been given any effective pain 5 medication. 6 IV. Failure to State a Claim 7 To state a claim under § 1983 against a private entity performing a traditional public 8 function, such as providing medical care to prisoners, a plaintiff must allege facts to support 9 that his constitutional rights were violated as a result of a policy, decision, or custom 10 promulgated or endorsed by the private entity. See Tsao v. Desert Palace, Inc., 698 F.3d 11 1128, 1138-39 (9th Cir. 2012); Buckner v. Toro, 116 F.3d 450, 452 (11th Cir. 1997) (per 12 curiam). A plaintiff must allege the specific policy or custom and how it violated his 13 constitutional rights. A private entity is not liable merely because it employs persons who 14 allegedly violated a plaintiff’s constitutional rights. See Tsao, 698 F.3d at 1139; Buckner, 15 116 F.3d at 452. 16 Plaintiff alleges that NaphCare’s failure to “take steps to ensure that [he] received 17 the needed treatment and care, despite its knowledge of [his] serious medical needs, 18 constituted deliberate indifference to [his] serious medical needs.” However, Plaintiff has 19 not provided any factual detail regarding any of the responses to the HNRs he submitted 20 or the treatment he received. Plaintiff states that he underwent blood tests and diagnostic 21 imaging, but he does not state when these tests occurred, the results of the tests, any 22 diagnoses he received, what, if any, treatment was recommended, what treatment Plaintiff 23 received, and, if any recommended treatment was denied, the reasons given for the denial. 24 Plaintiff also contends Defendant NaphCare “has a custom and/or policy of ignoring 25 the recommendations made by its providers.” That allegation is insufficient to state a claim 26 against NaphCare. Plaintiff provides virtually no factual detail concerning his providers’ 27 recommendations. Although Plaintiff claims Blanck-Miller requested surgery and a visit 28 with a dermatologist, Plaintiff provides no facts regarding these requests, such as when 1 Blanck-Miller made the requests, the reasons she gave for the requests, the nature of the 2 surgery she requested, when and by whom the requests were denied, the reasons given for 3 the denial, and whether any alternative treatment plans were implemented. As presented, 4 Plaintiff fails to state a claim against NaphCare, the sole Defendant. The Court will 5 therefore dismiss the Complaint with leave to amend. 6 V. Leave to Amend 7 Within 30 days, Plaintiff may submit a first amended complaint to cure the 8 deficiencies outlined above. The Clerk of Court will mail Plaintiff a court-approved form 9 to use for filing a first amended complaint. 10 Plaintiff must clearly designate on the face of the document that it is the “First 11 Amended Complaint.” The first amended complaint must be retyped or rewritten in its 12 entirety on the court-approved form and may not incorporate any part of the original 13 Complaint by reference. Plaintiff may include only one claim per count. 14 A first amended complaint supersedes the original Complaint. Ferdik v. Bonzelet, 15 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 F.2d 16 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat the original Complaint 17 as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the 18 original Complaint and that was voluntarily dismissed or was dismissed without prejudice 19 is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa County, 693 20 F.3d 896, 928 (9th Cir. 2012) (en banc). 21 VI. Warnings 22 A. Release 23 If Plaintiff is released while this case remains pending, and the filing fee has not 24 been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 25 that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 26 (2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 27 result in dismissal of this action. 28 . . . . 1 B. Address Changes 2 Plaintiff must file and serve a notice of a change of address in accordance with Rule 3 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion for other 4 relief with a notice of change of address. Failure to comply may result in dismissal of this 5 action. 6 C. Possible “Strike” 7 Because the Complaint has been dismissed for failure to state a claim, if Plaintiff 8 fails to file an amended complaint correcting the deficiencies identified in this Order, the 9 dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 10 Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 11 judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more prior 12 occasions, while incarcerated or detained in any facility, brought an action or appeal in a 13 court of the United States that was dismissed on the grounds that it is frivolous, malicious, 14 or fails to state a claim upon which relief may be granted, unless the prisoner is under 15 imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). 16 D. Possible Dismissal 17 If Plaintiff fails to timely comply with every provision of this Order, including these 18 warnings, the Court may dismiss this action without further notice. See Ferdik, 963 F.2d 19 at 1260-61 (a district court may dismiss an action for failure to comply with any order of 20 the Court). 21 IT IS ORDERED: 22 (1) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted. 23 (2) As required by the accompanying Order to the appropriate government 24 agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee 25 of $26.78. 26 (3) The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff 27 has 30 days from the date this Order is filed to file a first amended complaint in compliance 28 with this Order. 1 (4) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 2| Court must, without further notice, enter a judgment of dismissal of this action with prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g) 4| and deny any pending unrelated motions as moot. 5 (5) The Clerk of Court must mail Plaintiffa court-approved form for filing a civil 6| rights complaint by a prisoner. 7 Dated this 16th day of January, 2025. 8 ? ' 10 a iC , C James A. Teilborg 11 Senior United States District Judge 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

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Instructions for a Prisoner Filing a Civil Rights Complaint in the United States District Court for the District of Arizona

1. Who May Use This Form. The civil rights complaint form is designed to help incarcerated persons prepare a complaint seeking relief for a violation of their federal civil rights. These complaints typically concern, but are not limited to, conditions of confinement. This form should not be used to challenge your conviction or sentence. If you want to challenge a state conviction or sentence, you should file a petition under 28 U.S.C. ' 2254 for a writ of habeas corpus by a person in state custody. If you want to challenge a federal conviction or sentence, you should file a motion under 28 U.S.C. § 2255 to vacate sentence in the federal court that entered the judgment. 2. The Form. Local Rule of Civil Procedure (LRCiv) 3.4 provides that complaints by incarcerated persons must be filed on the court-approved form. The form must be typed or neatly handwritten. The form must be completely filled in to the extent applicable. All questions must be answered clearly and concisely in the appropriate space on the form. If needed, you may attach additional pages, but no more than fifteen additional pages, of standard letter-sized paper. You must identify which part of the complaint is being continued and number all pages. If you do not fill out the form properly, you will be asked to submit additional or corrected information, which may delay the processing of your action. You do not need to cite law. 3. Your Signature. You must tell the truth and sign the form. If you make a false statement of a material fact, you may be prosecuted for perjury. 4. The Filing and Administrative Fees. The total fees for this action are $405.00 ($350.00 filing fee plus $55.00 administrative fee). If you are unable to immediately pay the fees, you may request leave to proceed in forma pauperis. Please review the “Information for Prisoners Seeking Leave to Proceed with a (Non-Habeas) Civil Action in Federal Court In Forma Pauperis Pursuant to 28 U.S.C. ' 1915” for additional instructions. 5. Original and Judge=s Copy. You must send an original plus one copy of your complaint and of any other documents submitted to the Court. You must send one additional copy to the Court if you wish to have a file-stamped copy of the document returned to you. All copies must be identical to the original. Copies may be legibly handwritten. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. 6. Where to File. You should file your complaint in the division where you were confined when your rights were allegedly violated. See LRCiv 5.1(a) and 77.1(a). If you were confined in Maricopa, Pinal, Yuma, La Paz, or Gila County, file in the Phoenix Division. If you were confined in Apache, Navajo, Coconino, Mohave, or Yavapai County, file in the Prescott Division. If you were confined in Pima, Cochise, Santa Cruz, Graham, or Greenlee County, file in the Tucson Division. Unless you are an inmate housed at an Arizona Department of Corrections facility that participates in electronic filing, mail the original and one copy of the complaint with the $405 filing and administrative fees or the application to proceed in forma pauperis to:

1 Revised 11/6/24 Phoenix & Prescott Divisions: OR Tucson Division: U.S. District Court Clerk U.S. District Court Clerk U.S. Courthouse, Suite 130 U.S. Courthouse, Suite 1500 401 West Washington Street, SPC 10 405 West Congress Street Phoenix, Arizona 85003-2119 Tucson, Arizona 85701-5010

7. Change of Address. You must immediately notify the Court and the defendants in writing of any change in your mailing address. Failure to notify the Court of any change in your mailing address may result in the dismissal of your case.

8. Certificate of Service. You must furnish the defendants with a copy of any document you submit to the Court (except the initial complaint and application to proceed in forma pauperis). Each original document (except the initial complaint and application to proceed in forma pauperis) must include a certificate of service on the last page of the document stating the date a copy of the document was mailed to the defendants and the address to which it was mailed. See Fed. R. Civ. P. 5(a), (d). Any document received by the Court that does not include a certificate of service may be stricken. This section does not apply to inmates housed at an Arizona Department of Corrections facility that participates in electronic filing. A certificate of service should be in the following form:

I hereby certify that a copy of the foregoing document was mailed this (month, day, year) to: Name: Address: Attorney for Defendant(s)

(Signature)

9. Amended Complaint. If you need to change any of the information in the initial complaint, you must file an amended complaint. The amended complaint must be written on the court- approved civil rights complaint form. You may file one amended complaint without leave (permission) of Court within 21 days after serving it or within 21 days after any defendant has filed an answer, whichever is earlier. See Fed. R. Civ. P. 15(a). Thereafter, you must file a motion for leave to amend and lodge (submit) a proposed amended complaint. LRCiv 15.1. In addition, an amended complaint may not incorporate by reference any part of your prior complaint. LRCiv 15.1(a)(2). Any allegations or defendants not included in the amended complaint are considered dismissed. All amended complaints are subject to screening under the Prison Litigation Reform Act; screening your amendment will take additional processing time.

10. Exhibits. You should not submit exhibits with the complaint or amended complaint. Instead, the relevant information should be paraphrased. You should keep the exhibits to use to support or oppose a motion to dismiss, a motion for summary judgment, or at trial.

11. Letters and Motions. It is generally inappropriate to write a letter to any judge or the staff of any judge. The only appropriate way to communicate with the Court is by filing a written pleading or motion.

2 12. Completing the Civil Rights Complaint Form.

HEADING: 1. Your Name. Print your name, prison or inmate number, and institutional mailing address on the lines provided.

2. Defendants. If there are four or fewer defendants, print the name of each. If you name more than four defendants, print the name of the first defendant on the first line, write the words “and others” on the second line, and attach an additional page listing the names of all of the defendants. Insert the additional page after page 1 and number it “1- A” at the bottom.

3. Jury Demand. If you want a jury trial, you must write “JURY TRIAL DEMANDED” in the space below “CIVIL RIGHTS COMPLAINT BY A PRISONER.” Failure to do so may result in the loss of the right to a jury trial. A jury trial is not available if you are seeking only injunctive relief.

Part A. JURISDICTION: 1. Nature of Suit. Mark whether you are filing the complaint pursuant to 42 U.S.C. ' 1983 for state, county, or city defendants; “Bivens v. Six Unknown Federal Narcotics Agents” for federal defendants; or “other.” If you mark “other,” identify the source of that authority.

2. Location. Identify the institution and city where the alleged violation of your rights occurred.

3. Defendants. Print all of the requested information about each of the defendants in the spaces provided. If you are naming more than four defendants, you must provide the necessary information about each additional defendant on separate pages labeled “2-A,” “2-B,” etc., at the bottom. Insert the additional page(s) immediately behind page 2.

Part B. PREVIOUS LAWSUITS: You must identify any other lawsuit you have filed in either state or federal court while you were a prisoner. Print all of the requested information about each lawsuit in the spaces provided. If you have filed more than three lawsuits, you must provide the necessary information about each additional lawsuit on a separate page. Label the page(s) as “2-A,” “2-B,” etc., at the bottom of the page and insert the additional page(s) immediately behind page 2.

Part C. CAUSE OF ACTION: You must identify what rights each defendant violated. The form provides space to allege three separate counts (one violation per count). If you are alleging more than three counts, you must provide the necessary information about each additional count on a separate page. Number the additional pages “5-A,” “5-B,” etc., and insert them immediately behind page 5. Remember that you are limited to a total of fifteen additional pages.

3 1. Counts. You must identify which civil right was violated. You may allege the violation of only one civil right per count.

2. Issue Involved. Check the box that most closely identifies the issue involved in your claim. You may check only one box per count. If you check the box marked “Other,” you must identify the specific issue involved.

3. Supporting Facts. After you have identified which civil right was violated, you must state the supporting facts. Be as specific as possible. You must state what each individual defendant did to violate your rights. If there is more than one defendant, you must identify which defendant did what act. You also should state the date(s) on which the act(s) occurred, if possible.

4. Injury. State precisely how you were injured by the alleged violation of your rights.

5. Administrative Remedies. You must exhaust any available administrative remedies before you file a civil rights complaint. See 42 U.S.C. § 1997e. Consequently, you should disclose whether you have exhausted the inmate grievance procedures or administrative appeals for each count in your complaint. If the grievance procedures were not available for any of your counts, fully explain why on the lines provided.

Part D. REQUEST FOR RELIEF: Print the relief you are seeking in the space provided.

SIGNATURE: You must sign your name and print the date you signed the complaint. Failure to sign the complaint will delay the processing of your action. Unless you are an attorney, you may not bring an action on behalf of anyone but yourself.

FINAL NOTE

You should follow these instructions carefully. Failure to do so may result in your complaint being stricken or dismissed. All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number the pages.

4 ___________________________________________ Name and Prisoner/Booking Number ___________________________________________ Place of Confinement ___________________________________________ Mailing Address ___________________________________________ City, State, Zip Code (Failure to notify the Court of your change of address may result in dismissal of this action.)

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA

_________________________________________ , (Full Name of Plaintiff)

Plaintiff, v. CASE NO. __________________________________ (To be supplied by the Clerk) (1) _______________________________________ , (Full Name of Defendant) CIVIL RIGHTS COMPLAINT (2) _______________________________________ , BY A PRISONER

(3) _______________________________________ , G Original Complaint (4) _______________________________________ , G First Amended Complaint G Second Amended Complaint Defendant(s).

G Check if there are additional Defendants and attach page 1-A listing them.

A. JURISDICTION

1. This Court has jurisdiction over this action pursuant to: G 28 U.S.C. § 1343(a); 42 U.S.C. § 1983 G 28 U.S.C. § 1331; Bivens v. Six Unknown Federal Narcotics Agents, 403 U.S. 388 (1971). G Other: .

2. Institution/city where violation occurred: .

550/555 B. DEFENDANTS

1. Name of first Defendant: . The first Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

2. Name of second Defendant: . The second Defendant is employed as: as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

3. Name of third Defendant: . The third Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

4. Name of fourth Defendant: . The fourth Defendant is employed as: ______________________________________________ at_______________________________________. (Position and Title) (Institution)

If you name more than four Defendants, answer the questions listed above for each additional Defendant on a separate page.

C. PREVIOUS LAWSUITS

1. Have you filed any other lawsuits while you were a prisoner? G Yes G No

2. If yes, how many lawsuits have you filed? . Describe the previous lawsuits:

a. First prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

b. Second prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

c. Third prior lawsuit: 1. Parties: v. 2. Court and case number: . 3. Result: (Was the case dismissed? Was it appealed? Is it still pending?) .

If you filed more than three lawsuits, answer the questions listed above for each additional lawsuit on a separate page. D. CAUSE OF ACTION

COUNT I 1. State the constitutional or other federal civil right that was violated: .

2. Count I. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count I. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies: a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count I? G Yes G No c. Did you appeal your request for relief on Count I to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

3 COUNT II 1. State the constitutional or other federal civil right that was violated: .

2. Count II. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count II. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count II? G Yes G No c. Did you appeal your request for relief on Count II to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

4 COUNT III 1. State the constitutional or other federal civil right that was violated: .

2. Count III. Identify the issue involved. Check only one. State additional issues in separate counts. G Basic necessities G Mail G Access to the court G Medical care G Disciplinary proceedings G Property G Exercise of religion G Retaliation G Excessive force by an officer G Threat to safety G Other: .

3. Supporting Facts. State as briefly as possible the FACTS supporting Count III. Describe exactly what each Defendant did or did not do that violated your rights. State the facts clearly in your own words without citing legal authority or arguments.

4. Injury. State how you were injured by the actions or inactions of the Defendant(s).

5. Administrative Remedies. a. Are there any administrative remedies (grievance procedures or administrative appeals) available at your institution? G Yes G No b. Did you submit a request for administrative relief on Count III? G Yes G No c. Did you appeal your request for relief on Count III to the highest level? G Yes G No d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. .

If you assert more than three Counts, answer the questions listed above for each additional Count on a separate page.

5 E. REQUEST FOR RELIEF

State the relief you are seeking:

I declare under penalty of perjury that the foregoing is true and correct.

Executed on DATE SIGNATURE OF PLAINTIFF

___________________________________________ (Name and title of paralegal, legal assistant, or other person who helped prepare this complaint)

___________________________________________ (Signature of attorney, if any)

___________________________________________ (Attorney=s address & telephone number)

ADDITIONAL PAGES

All questions must be answered concisely in the proper space on the form. If you need more space, you may attach no more than fifteen additional pages. But the form must be completely filled in to the extent applicable. If you attach additional pages, be sure to identify which section of the complaint is being continued and number all pages.