Rogers v. Phoenix Memorial Hospital, No. 2:2007cv00379 - Document 10 (D. Ariz. 2007)
Court Description: ORDER granting 9 Motion for Reconsideration; the judgment entered on 5/11/07 8 is vacated and Clerk or Court must reopen this action. Granting 6 Motion for Leave to Proceed in forma pauperis. As required by the accompanying Order to the appro priate government agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee of $11.56. Plaintiff's "Motion To Request A Copy of the Complaint" (Doc. #7) is denied. The Complaint (Doc. # 1) is dismissed for failure to state a claim. Plaintiff has 30 days from the date this Order is filed to file a first amended complaint in compliance with this Order. If Plaintiff fails to file an amended complaint within 30 days, the Clerk of Court must, without further notice, enter a judgment of dismissal of this action with prejudice that states that the dismissal counts as a strike under 28 U.S.C. § 1915(g). The Clerk of Court must mail Plaintiff the court-approved form for filing a civil rights complaint by a prisoner.Signed by Judge David G Campbell on 6/18/07.(DMT, )
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Rogers v. Phoenix Memorial Hospital Doc. 10 1 2 RP WO 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Laura Ann Rogers, Plaintiff, 10 11 vs. 12 Phoenix Memorial Hospital, 13 Defendant. ) ) ) ) ) ) ) ) ) ) No. CV 07-379-PHX-DGC (DKD) ORDER 14 15 On February 20, 2007, Plaintiff Laura Ann Rogers, who is confined in the Maricopa 16 County Estrella Jail, filed a pro se civil rights Complaint (Doc. #1) pursuant to 42 U.S.C. 17 § 1983. Plaintiff did not pay the $350.00 civil action filing fee but filed an uncertified 18 Application to Proceed In Forma Pauperis. 19 By Order filed February 27, 2007 (Doc. #3), the Court denied Plaintiff's Application 20 to Proceed In Forma Pauperis without prejudice and gave Plaintiff 30 days from the filing 21 date of the Order to either pay the $350.00 filing fee or file a completed Application to 22 Proceed In Forma Pauperis and a six-month trust account statement. 23 On March 19, 2007, Plaintiff filed a "Motion - Request for Additional Time" (Doc. 24 #4). By Order filed March 23, 2007 (Doc. #5), Plaintiff's Motion was granted and Plaintiff 25 was given 30 days from the filing date of the Order to either pay the $350.00 filing fee or file 26 a new Application to Proceed In Forma Pauperis and a six-month trust account statement. 27 Unbeknownst to the Court, at the time the Court's March 23, 2007 Order was filed, 28 JDDL-K Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 1 of 16 Dockets.Justia.com 1 Plaintiff had already filed a new Application to Proceed In Forma Pauperis and a six-month 2 trust account statement (Doc. #6) on March 22, 2007. On May 11, 2007, the Clerk of Court 3 inadvertently entered a judgement of dismissal of the Complaint and this action (Doc. #8) 4 because Plaintiff had not paid the $350.00 filing fee or filed a new Application to Proceed 5 In Forma Pauperis and a six-month trust account statement in response to the Court's March 6 23, 2007 Order. 7 I. Motion to Reconsider 8 On May 31, 2007, Plaintiff filed a "Motion to reconsider case closed" (Doc. #9), in 9 which Plaintiff states that she cannot find where she failed to comply with this Court's orders. 10 For good cause shown, Plaintiff's Motion will be granted and the Court will direct the Clerk 11 of Court to vacate the judgment entered on May 11, 2007 and to reopen this action. 12 II. Application to Proceed In Forma Pauperis and Filing Fee 13 Plaintiff’s Application to Proceed In Forma Pauperis (Doc. #6) will be granted. 28 14 U.S.C. § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. 15 § 1915(b)(1). The Court will assess an initial partial filing fee of $11.56. 28 U.S.C. 16 § 1915(b)(1). The remainder of the fee will be collected monthly in payments of 20% of the 17 previous month’s income each time the amount in the account exceeds $10.00. 28 U.S.C. 18 § 1915(b)(2). The Court will enter a separate Order requiring the appropriate government 19 agency to collect and forward the fees according to the statutory formula. 20 III. Statutory Screening of Prisoner Complaints 21 The Court is required to screen complaints brought by prisoners seeking relief against 22 a governmental entity or an officer or an employee of a governmental entity. 28 U.S.C. 23 § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff has raised 24 claims that are legally frivolous or malicious, that fail to state a claim upon which relief may 25 be granted, or that seek monetary relief from a defendant who is immune from such relief. 26 28 U.S.C. § 1915A(b)(1), (2). If the Court determines that a pleading could be cured by the 27 allegation of other facts, a pro se litigant is entitled to an opportunity to amend a complaint 28 before dismissal of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) JDDL-K Case 2:07-cv-00379-DGC--DKD -2Document 10 Filed 06/18/2007 Page 2 of 16 1 (en banc). 2 The Court should not, however, advise the litigant how to cure the defects. This type 3 of advice “would undermine district judges’ role as impartial decisionmakers.” Pliler v. 4 Ford, 542 U.S. 225, 231 (2004); see also Lopez, 203 F.3d at 1131 n.13 (declining to decide 5 whether the court was required to inform a litigant of deficiencies). Plaintiff’s Complaint 6 will be dismissed for failure to state a claim, with leave to amend because the Complaint may 7 possibly be saved by amendment. 8 IV. Complaint 9 Plaintiff alleges two counts in her Complaint. In Count I, Plaintiff claims that her 10 Fourth Amendment rights were violated when she was held down against her will by 11 Emergency Room staff at Phoenix Memorial Hospital while they did a full cavity search of 12 her vagina without probable cause. In Count II, Plaintiff claims that her Fourth Amendment 13 rights were violated when she was held against her will by Emergency Room staff at Phoenix 14 Memorial Hospital to do a cavity search and an unauthorized "cath[et]er." Named as 15 Defendant in the Complaint is the Phoenix Memorial Hospital. Plaintiff seeks monetary 16 damages and victim/rape awareness training for Defendant. 17 V. Improper Defendant 18 To state a claim under 42 U.S.C. § 1983, Plaintiff must allege: (1) the conduct 19 complained of was committed by a person acting under color of state law; and (2) the 20 conduct deprived the Plaintiff of a constitutional right. Balisteri v. Pacifica Police Dep't, 901 21 F.2d 696, 699 (9th Cir. 1988). Defendant Phoenix Memorial Hospital appears to be a private 22 actor that was not acting under color of state law. 23 Furthermore, there is no liability under 42 U.S.C. § 1983 based on a theory of 24 respondeat superior. Monell v. New York City Dept. of Social Services, 436 U.S. 658, 691 25 (1978); West v. Atkins, 487 U.S. 42, 54 n.12 (1988); Ybarra v. Reno Thunderbird Mobile 26 Home Village, 723 F.2d 675, 680-81 (9th Cir. 1984). A private corporation can be found 27 liable in an action pursuant to 42 U.S.C. § 1983 if it is acting under color of state law and the 28 constitutional deprivations resulted from a policy, custom, or practice of the private JDDL-K Case 2:07-cv-00379-DGC--DKD -3Document 10 Filed 06/18/2007 Page 3 of 16 1 corporation. See Robinson v. City of San Bernadino Police Department, 992 F.Supp. 1198, 2 1204 (C.D.Cal. 1998). Because there is no liability under 42 U.S.C. § 1983 based on a 3 theory of respondeat superior, Defendant cannot be held liable simply because Emergency 4 Room staff were employed by the Hospital. Nor does Plaintiff claim that her injuries 5 resulted from a policy, custom, or practice of Phoenix Memorial Hospital. 6 Accordingly, Phoenix Memorial Hospital is not a proper Defendant to this action and 7 is subject to dismissal without prejudice from this action for failure to state a claim upon 8 which relief may be granted. 9 VI. Leave to Amend 10 Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519 (1972), 11 conclusory and vague allegations will not support a cause of action. Ivey v. Board of Regents of the 12 University of Alaska, 673 F.2d 266 (9th Cir. 1982); Rhodes v. Robinson, 612 F.2d 766, 772 (3rd. 13 Cir. 1979). Further, a liberal interpretation of a civil rights complaint may not supply essential 14 elements of the claim that were not initially pled. Ivey, 673 F.2d at 268. 15 Because no Defendant now remains, Plaintiff’s Complaint will be dismissed for 16 failure to state a claim upon which relief may be granted. Within 30 days, Plaintiff may 17 submit a first amended complaint to cure the deficiencies outlined above. The Clerk of Court 18 will mail Plaintiff a court-approved form to use for a first amended complaint. If Plaintiff 19 fails to use the court-approved form, the Court may strike the amended complaint and 20 dismiss this action without further notice to Plaintiff. 21 Plaintiff must clearly designate on the face of the document that it is the “First 22 Amended Complaint.” The first amended complaint must be retyped or rewritten in its 23 entirety on the court-approved form and may not incorporate any part of the original 24 Complaint by reference. Plaintiff may include only one claim per count. 25 A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 963 26 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 F.2d 1542, 27 1546 (9th Cir. 1990). After amendment, the Court will treat an original complaint as 28 nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised in the original JDDL-K Case 2:07-cv-00379-DGC--DKD -4Document 10 Filed 06/18/2007 Page 4 of 16 1 complaint is waived if it is not raised in a first amended complaint. King v. Atiyeh, 814 F.2d 2 565, 567 (9th Cir. 1987). 3 VII. Motion for Copy of Complaint 4 On March 27, 2007, Plaintiff filed a "Motion To Request A Copy of the Complaint" 5 (Doc. #7). In light of the dismissal of the Complaint with leave to amend, Plaintiff's Motion 6 will be denied. 7 VIII. Warnings 8 A. 9 Plaintiff must pay the unpaid balance of the filing fee within 120 days of her release. 10 Also, within 30 days of her release, Plaintiff must either (1) notify the Court that she intends 11 to pay the balance or (2) show good cause, in writing, why she cannot. Failure to comply 12 may result in dismissal. Release 13 B. Address Changes 14 Plaintiff must file and serve a notice of a change of address 10 days before the move 15 is effective, if practicable. See LRCiv 83.3(d). Plaintiff must not include a motion for other 16 relief with a notice of change of address. Failure to comply may result in dismissal. 17 C. Copies 18 Plaintiff must submit an additional copy of every document that she files for use by 19 the Court. See LRCiv 5.4. Failure to comply may result in the filing being stricken without 20 further notice to Plaintiff. 21 D. Possible “Strike” 22 Because the Complaint has been dismissed for failure to state a claim, if Plaintiff fails 23 to file an amended complaint correcting the deficiencies identified in this Order, the 24 dismissal will count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 25 Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 26 judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more prior 27 occasions, while incarcerated or detained in any facility, brought an action or appeal in a 28 court of the United States that was dismissed on the grounds that it is frivolous, malicious, JDDL-K Case 2:07-cv-00379-DGC--DKD -5Document 10 Filed 06/18/2007 Page 5 of 16 1 or fails to state a claim upon which relief may be granted, unless the prisoner is under 2 imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). 3 E. 4 Plaintiff is warned that failure to timely comply with every provision of this Order, 5 including these warnings, may result in dismissal of this action without further notice. See 6 Ferdik, 963 F.2d at 1260-61 (a district court may dismiss an action for failure to comply with 7 any order of the Court). 8 IT IS ORDERED: 9 (1) Possible Dismissal Plaintiff's "Motion to reconsider case closed" (Doc. #9) is granted, the 10 judgment entered in this action on May 11, 2007 (Doc. #8) is vacated, and the Clerk or Court 11 must reopen this action. 12 (2) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. #6) is granted. 13 (3) As required by the accompanying Order to the appropriate government agency, 14 Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing fee of $11.56. 15 (4) Plaintiff's "Motion To Request A Copy of the Complaint" (Doc. #7) is denied. 16 (5) The Complaint (Doc. #1) is dismissed for failure to state a claim. Plaintiff has 17 30 days from the date this Order is filed to file a first amended complaint in compliance with 18 this Order. 19 (6) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 20 Court must, without further notice, enter a judgment of dismissal of this action with prejudice 21 that states that the dismissal counts as a “strike” under 28 U.S.C. § 1915(g). 22 23 24 (7) The Clerk of Court must mail Plaintiff the court-approved form for filing a civil rights complaint by a prisoner. DATED this 18th day of June, 2007. 25 26 27 28 JDDL-K Case 2:07-cv-00379-DGC--DKD -6Document 10 Filed 06/18/2007 Page 6 of 16 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(a) 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 Fee. The filing fee for this action is $350.00. If you are unable to immediately pay the filing fee, 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. 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. Mail the original and one copy of the complaint with the $350 filing fee or the application to proceed in forma pauperis to: Revised 3/9/07 Case 2:07-cv-00379-DGC--DKD 1 Document 10 Filed 06/18/2007 Page 7 of 16 Phoenix & Prescott Divisions: OR U.S. District Court Clerk U.S. Courthouse, Suite 130 401 West Washington Street, SPC 10 Phoenix, Arizona 85003-2119 Tucson Division: U.S. District Court Clerk U.S. Courthouse, Suite 1500 405 West Congress Street 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. 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 courtapproved civil rights complaint form. You may file one amended complaint without leave (permission) of Court before any defendant has answered your original complaint. See Fed. R. Civ. P. 15(a). After any defendant has filed an answer, 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 8 of 16 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 “1A” 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,” “2B,” 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 9 of 16 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 10 of 16 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, vs. (1) (Full Name of Defendant) (2) (3) (4) Defendant(s). G Check if there are additional Defendants and attach page 1-A listing them. ) , ) ) ) ) CASE NO. ) (To be supplied by the Clerk) , ) ) , ) CIVIL RIGHTS COMPLAINT ) , ) BY A PRISONER ) , ) G Original Complaint G First Amended Complaint ) ) G Second Amended Complaint A. JURISDICTION 1. 2. 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: . Institution/city where violation occurred: . Revised 3/9/07 Case 2:07-cv-00379-DGC--DKD 550/555 1 Document 10 Filed 06/18/2007 Page 11 of 16 B. DEFENDANTS 1. Name of first Defendant: . The first Defendant is employed as: . at (Position and Title) 2. (Institution) Name of second Defendant: . The second Defendant is employed as: . at (Position and Title) 3. (Institution) Name of third Defendant: . The third Defendant is employed as: . at (Position and Title) 4. (Institution) 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? 2. If yes, how many lawsuits have you filed? G Yes G No . 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: v. 1. Parties: 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. 2 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 12 of 16 D. CAUSE OF ACTION 1. COUNT I 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 G Yes G No at your institution? 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 13 of 16 1. COUNT II 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 14 of 16 1. COUNT III 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 G Yes G No at your institution? 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 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 15 of 16 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. 6 Case 2:07-cv-00379-DGC--DKD Document 10 Filed 06/18/2007 Page 16 of 16
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