Shaka v. Ryan et al, No. 2:2015cv00050 - Document 8 (D. Ariz. 2015)

Court Description: ORDER granting 2 Plaintiff's Application to Proceed In Forma Pauperis. Plaintiff must pay the $350.00 filing fee. Plaintiff's Notice of Compliance and Motion that "Unknown" not be used in the case caption (Doc. 5 ) is gr anted. Plaintiff's Notice of Compliance and Motion for Confirmation (Doc. 7 ) is granted to the extent set forth in this order. The complaint is dismissed with 30 days leave to amend. Clerk must enter dismissal with prejudice that states that the dismissal may count as a "strike" under 28 U.S.C. § 1915(g) if Plaintiff fails to comply. Signed by Senior Judge Stephen M McNamee on 5/11/15.(LSP)
Download PDF
Shaka v. Ryan et al 1 Doc. 8 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8 9 Shaka, No. CV 15-0050-PHX-SMM (BSB) 10 Plaintiff, 11 12 v. ORDER Charles L. Ryan, et al., 13 Defendants. 14 15 On January 12, 2015, Plaintiff Shaka, who is confined in the Arizona State Prison 16 Complex-Yuma, filed a pro se civil rights Complaint pursuant to 42 U.S.C. § 1983 (Doc. 17 1) and an Application to Proceed In Forma Pauperis (Doc. 2). In a February 13, 2015 18 Order, the Court denied the Application to Proceed because Plaintiff had failed to submit 19 a certified trust account statement. 20 Compliance and Motion that “Unknown” not be used in the case caption (“Motion”) 21 (Doc. 5) and a certified six-moth trust account statement. On May 7, 2015, Plaintiff filed 22 a Notice of Compliance and Motion for Confirmation (Doc. 7). The Court will grant the 23 Application to Proceed1 and the Motions, but will dismiss the Complaint with leave to 24 amend. 25 I. 26 On March 2, 2015, Plaintiff filed a Notice of Application to Proceed In Forma Pauperis and Filing Fee Plaintiff’s Application to Proceed In Forma Pauperis will be granted. 28 U.S.C. 27 28 1 The Court considered Plaintiff’s Application to Proceed In Forma Pauperis filed on January 12, 2015 and the trust account statement filed on March 2, 2015. JDDL-K Dockets.Justia.com 1 § 1915(a). Plaintiff must pay the statutory filing fee of $350.00. 28 U.S.C. § 1915(b)(1). 2 The Court will assess an initial partial filing fee of $8.17. The remainder of the fee will 3 be collected monthly in payments of 20% of the previous month’s income credited to 4 Plaintiff’s trust account each time the amount in the account exceeds $10.00. 28 U.S.C. 5 § 1915(b)(2). The Court will enter a separate Order requiring the appropriate government 6 agency to collect and forward the fees according to the statutory formula. 7 II. Statutory Screening of Prisoner Complaints 8 The Court is required to screen complaints brought by prisoners seeking relief 9 against a governmental entity or an officer or an employee of a governmental entity. 28 10 U.S.C. § 1915A(a). The Court must dismiss a complaint or portion thereof if a plaintiff 11 has raised claims that are legally frivolous or malicious, that fail to state a claim upon 12 which relief may be granted, or that seek monetary relief from a defendant who is 13 immune from such relief. 28 U.S.C. § 1915A(b)(1)–(2). 14 A pleading must contain a “short and plain statement of the claim showing that the 15 pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2) (emphasis added). While Rule 8 16 does not demand detailed factual allegations, “it demands more than an unadorned, the- 17 defendant-unlawfully-harmed-me accusation.” 18 (2009). “Threadbare recitals of the elements of a cause of action, supported by mere 19 conclusory statements, do not suffice.” Id. Ashcroft v. Iqbal, 556 U.S. 662, 678 20 21 claim to relief that is plausible on its face.’” Id. (quoting Bell Atlantic Corp. v. Twombly, 22 550 U.S. 544, 570 (2007)). A claim is plausible “when the plaintiff pleads factual 23 content that allows the court to draw the reasonable inference that the defendant is liable 24 for the misconduct alleged.” Id. “Determining whether a complaint states a plausible 25 claim for relief [is] . . . a context-specific task that requires the reviewing court to draw 26 on its judicial experience and common sense.” Id. at 679. Thus, although a plaintiff’s 27 specific factual allegations may be consistent with a constitutional claim, a court must 28 JDDL-K “[A] complaint must contain sufficient factual matter, accepted as true, to ‘state a assess whether there are other “more likely explanations” for a defendant’s conduct. Id. -2- 1 at 681. 2 But as the United States Court of Appeals for the Ninth Circuit has instructed, 3 courts must “continue to construe pro se filings liberally.” Hebbe v. Pliler, 627 F.3d 338, 4 342 (9th Cir. 2010). A “complaint [filed by a pro se prisoner] ‘must be held to less 5 stringent standards than formal pleadings drafted by lawyers.’” Id. (quoting Erickson v. 6 Pardus, 551 U.S. 89, 94 (2007) (per curiam)). 7 If the Court determines that a pleading could be cured by the allegation of other 8 facts, a pro se litigant is entitled to an opportunity to amend a complaint before dismissal 9 of the action. See Lopez v. Smith, 203 F.3d 1122, 1127-29 (9th Cir. 2000) (en banc). 10 Plaintiff’s Complaint will be dismissed for failure to state a claim, but because it may 11 possibly be amended to state a claim, the Court will dismiss it with leave to amend. 12 III. Complaint 13 In his one-count Complaint, Plaintiff sues Defendants Charles L. Ryan, Director of 14 Arizona Department of Corrections; Anthony N. Medel, M.B.A., employed as “facility 15 health”; Lori Johnson, Facility Health Administrator/Corizon Site Manager at ASPC- 16 Yuma’s Dakota Unit; and Richard Pratt, Interim Division Director of Health Services at 17 Central Office. Plaintiff seeks injunctive relief and monetary damages. 18 19 and alleges the following facts: Since January 2013, Plaintiff has been trying to have his 20 knee problems diagnosed and corrected in order to relieve the pain he has both knees. On 21 February 24, 2014, Plaintiff had an MRI on his right knee that showed he had a cleavage 22 tear of the posterior horn and body of the medial meniscus, an equivocal tear in the 23 anterior horn of the lateral meniscus, and chondromalacia and small cleavage tears of the 24 patellar cartilage. An MRI of the left knee on the same day showed that he had an 25 oblique tear in the posterior horn of the medial meniscus and subchondral cystic changes 26 involving the medial tibial plateau. At some point, Plaintiff was seen by Dr. Vanderhooh, 27 who informed Plaintiff that he needed to have knee surgery. On December 19, 2014, 28 JDDL-K Plaintiff asserts a claim for the denial of constitutionally adequate medical care Plaintiff was seen by Dr. Lutrill, who “wanted to give a new injection to see how it -3- 1 worked,” but Dr. Lutrill told Plaintiff he could not treat him without first getting 2 Corizon’s approval. Dr. Lutrill also told Plaintiff that there were “bone on bone areas in 3 both knees” that required surgery. Plaintiff then returned to ASPC-Yuma’s Cheyenne 4 Unit to await Corizon and Central Office’s approval for treatment. 5 Plaintiff claims he has been denied knee surgery and injections to treat his knee 6 pain for almost two years. Plaintiff lives in constant pain and is unable to exercise. 7 Medical failed to inform Dr. Lutrill that the relief provided by the shot wore off after an 8 hour and a half. 9 IV. Failure to State a Claim 10 To prevail in a § 1983 claim, a plaintiff must show that (1) acts by the defendants 11 (2) under color of state law (3) deprived him of federal rights, privileges or immunities 12 and (4) caused him damage. Thornton v. City of St. Helens, 425 F.3d 1158, 1163-64 (9th 13 Cir. 2005) (quoting Shoshone-Bannock Tribes v. Idaho Fish & Game Comm’n, 42 F.3d 14 1278, 1284 (9th Cir. 1994)). In addition, a plaintiff must allege that he suffered a specific 15 injury as a result of the conduct of a particular defendant and he must allege an 16 affirmative link between the injury and the conduct of that defendant. Rizzo v. Goode, 17 423 at 371-72, 377 (1976). 18 Although pro se pleadings are liberally construed, Haines v. Kerner, 404 U.S. 519, 19 520-21 (1972), conclusory and vague allegations will not support a cause of action. Ivey 20 v. Bd. of Regents of the Univ. of Alaska, 673 F.2d 266, 268 (9th Cir. 1982). Further, a 21 liberal interpretation of a civil rights complaint may not supply essential elements of the 22 claim that were not initially pled. Id. 23 Plaintiff has failed to allege any facts against any named Defendant. Accordingly, 24 the Court will dismiss Defendants Ryan, Medel, Pratt, and Johnson and this Complaint 25 with leave to amend. 26 V. Leave to Amend 27 28 JDDL-K For the foregoing reasons, Plaintiff’s Complaint will be dismissed for failure to state a claim upon which relief may be granted. Within 30 days, Plaintiff may submit a -4- 1 first amended complaint to cure the deficiencies outlined above. The Clerk of Court will 2 mail Plaintiff a court-approved form to use for filing a first amended complaint. If 3 Plaintiff fails to use the court-approved form, the Court may strike the amended 4 complaint and dismiss this action without further notice to Plaintiff. 5 Plaintiff must clearly designate on the face of the document that it is the “First 6 Amended Complaint.” The first amended complaint must be retyped or rewritten in its 7 entirety on the court-approved form and may not incorporate any part of the original 8 Complaint by reference. Plaintiff may include only one claim per count. 9 If Plaintiff files an amended complaint, Plaintiff must write short, plain statements 10 telling the Court: (1) the constitutional right Plaintiff believes was violated; (2) the name 11 of the Defendant who violated the right; (3) exactly what that Defendant did or failed to 12 do; (4) how the action or inaction of that Defendant is connected to the violation of 13 Plaintiff’s constitutional right; and (5) what specific injury Plaintiff suffered because of 14 that Defendant’s conduct. See Rizzo v. Goode, 423 U.S. 362, 371-72, 377 (1976). 15 Plaintiff must repeat this process for each person he names as a Defendant. If 16 Plaintiff fails to affirmatively link the conduct of each named Defendant with the specific 17 injury suffered by Plaintiff, the allegations against that Defendant will be dismissed for 18 failure to state a claim. 19 Defendants has violated a constitutional right are not acceptable and will be 20 dismissed. Conclusory allegations that a Defendant or group of 21 A first amended complaint supersedes the original complaint. Ferdik v. Bonzelet, 22 963 F.2d 1258, 1262 (9th Cir. 1992); Hal Roach Studios v. Richard Feiner & Co., 896 23 F.2d 1542, 1546 (9th Cir. 1990). After amendment, the Court will treat an original 24 complaint as nonexistent. Ferdik, 963 F.2d at 1262. Any cause of action that was raised 25 in the original complaint and that was voluntarily dismissed or was dismissed without 26 prejudice is waived if it is not alleged in a first amended complaint. Lacey v. Maricopa 27 County, 693 F.3d 896, 928 (9th Cir. 2012) (en banc). 28 JDDL-K If Plaintiff files an amended complaint, he should be aware that not every claim by -5- 1 a prisoner relating to inadequate medical treatment states a violation of the Eighth or 2 Fourteenth Amendment. To state a § 1983 medical claim, a plaintiff must show that the 3 defendants acted with “deliberate indifference to serious medical needs.” Jett v. Penner, 4 439 F.3d 1091, 1096 (9th Cir. 2006) (quoting Estelle v. Gamble, 429 U.S. 97, 104 5 (1976)). 6 failure to treat the condition could result in further significant injury or the unnecessary 7 and wanton infliction of pain and (2) the defendant’s response was deliberately 8 indifferent. Jett, 439 F.3d at 1096 (quotations omitted). A plaintiff must show (1) a “serious medical need” by demonstrating that 9 “Deliberate indifference is a high legal standard.” Toguchi v. Chung, 391 F.3d 10 1051, 1060 (9th Cir. 2004). To act with deliberate indifference, a prison official must 11 both know of and disregard an excessive risk to inmate health; “the official must both be 12 aware of facts from which the inference could be drawn that a substantial risk of serious 13 harm exists, and he must also draw the inference.” Farmer v. Brennan, 511 U.S. 825, 14 837 (1994). 15 purposeful act or failure to respond to a prisoner’s pain or possible medical need and 16 harm caused by the indifference. Jett, 439 F.3d at 1096. Deliberate indifference may 17 also be shown when a prison official intentionally denies, delays, or interferes with 18 medical treatment or by the way prison doctors respond to the prisoner’s medical needs. 19 Estelle, 429 U.S. at 104-05; Jett, 439 F.3d at 1096. Deliberate indifference in the medical context may be shown by a 20 21 due care for the prisoner’s safety. Farmer, 511 U.S. at 835. “Neither negligence nor 22 gross negligence will constitute deliberate indifference.” Clement v. California Dep’t of 23 Corr., 220 F. Supp. 2d 1098, 1105 (N.D. Cal. 2002); see also Broughton v. Cutter Labs., 24 622 F.2d 458, 460 (9th Cir. 1980) (mere claims of “indifference,” “negligence,” or 25 “medical malpractice” do not support a claim under § 1983). “A difference of opinion 26 does not amount to deliberate indifference to [a plaintiff’s] serious medical needs.” 27 Sanchez v. Vild, 891 F.2d 240, 242 (9th Cir. 1989). A mere delay in medical care, 28 JDDL-K Deliberate indifference is a higher standard than negligence or lack of ordinary without more, is insufficient to state a claim against prison officials for deliberate -6- 1 indifference. See Shapley v. Nevada Bd. of State Prison Comm’rs, 766 F.2d 404, 407 2 (9th Cir. 1985). The indifference must be substantial. The action must rise to a level of 3 “unnecessary and wanton infliction of pain.” Estelle, 429 U.S. at 105. 4 VI. Plaintiff’s Motions 5 In Plaintiff’s Notice of Compliance and Motion (Doc. 5), he asks the Court to 6 remove the word “Unknown” from the case caption. When Plaintiff filed his Complaint, 7 he identified himself as “Shaka.” The Clerk of Court docketed Plaintiff’s name as 8 Unknown Shaka because of the apparent absence of a first name. Plaintiff notified the 9 Court that his entire legal name is Shaka, and that the Court has previously directed that 10 the word “Unknown” not be used (see Doc. 8 in CV 10-2253-PHX-SMM (D.Ariz, 11 2010)). The Court will grant Plaintiff’s Motion. 12 The Court will construe Plaintiff’s Notice of Compliance and Motion for 13 Confirmation (Doc.7) as a Motion for Case Status. The Court will grant the Motion for 14 Case Status to the extent this Order informs Plaintiff of the status of this case. 15 VII. Warnings 16 A. 17 If Plaintiff is released while this case remains pending, and the filing fee has not 18 been paid in full, Plaintiff must, within 30 days of his release, either (1) notify the Court 19 that he intends to pay the unpaid balance of his filing fee within 120 days of his release or 20 (2) file a non-prisoner application to proceed in forma pauperis. Failure to comply may 21 result in dismissal of this action. Release 22 23 Plaintiff must file and serve a notice of a change of address in accordance with 24 Rule 83.3(d) of the Local Rules of Civil Procedure. Plaintiff must not include a motion 25 for other relief with a notice of change of address. Failure to comply may result in 26 dismissal of this action. 27 .... 28 JDDL-K B. .... Address Changes -7- 1 C. 2 Plaintiff must submit an additional copy of every filing for use by the Court. See 3 LRCiv 5.4. Failure to comply may result in the filing being stricken without further 4 notice to Plaintiff. Copies 5 D. 6 Because the Complaint has been dismissed for failure to state a claim, if Plaintiff 7 fails to file an amended complaint correcting the deficiencies identified in this Order, the 8 dismissal may count as a “strike” under the “3-strikes” provision of 28 U.S.C. § 1915(g). 9 Under the 3-strikes provision, a prisoner may not bring a civil action or appeal a civil 10 judgment in forma pauperis under 28 U.S.C. § 1915 “if the prisoner has, on 3 or more 11 prior occasions, while incarcerated or detained in any facility, brought an action or appeal 12 in a court of the United States that was dismissed on the grounds that it is frivolous, 13 malicious, or fails to state a claim upon which relief may be granted, unless the prisoner 14 is under imminent danger of serious physical injury.” 28 U.S.C. § 1915(g). Possible “Strike” 15 E. 16 If Plaintiff fails to timely comply with every provision of this Order, including 17 these warnings, the Court may dismiss this action without further notice. See Ferdik, 963 18 F.2d at 1260-61 (a district court may dismiss an action for failure to comply with any 19 order of the Court). 20 IT IS ORDERED: Possible Dismissal 21 (1) Plaintiff’s Application to Proceed In Forma Pauperis (Doc. 2) is granted. 22 (2) As required by the accompanying Order to the appropriate government 23 agency, Plaintiff must pay the $350.00 filing fee and is assessed an initial partial filing 24 fee of $8.17. 25 26 27 28 JDDL-K (3) Plaintiff’s Notice of Compliance and Motion that “Unknown” not be used in the case caption (Doc. 5) is granted. (4) Plaintiff’s Notice of Compliance and Motion for Confirmation (Doc. 7) is granted to the extent set forth herein. -8- 1 (5) The Complaint (Doc. 1) is dismissed for failure to state a claim. Plaintiff 2 has 30 days from the date this Order is filed to file a first amended complaint in 3 compliance with this Order. 4 (6) If Plaintiff fails to file an amended complaint within 30 days, the Clerk of 5 Court must, without further notice, enter a judgment of dismissal of this action with 6 prejudice that states that the dismissal may count as a “strike” under 28 U.S.C. § 1915(g). 7 8 9 (7) The Clerk of Court must mail Plaintiff a court-approved form for filing a civil rights complaint by a prisoner. DATED this 11th day of May, 2015. 10 11 12 Honorable Stephen M. McNamee Senior United States District Judge 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 JDDL-K -9- 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 1 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 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 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, 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 1 550/555 B. DEFENDANTS 1. Name of first Defendant: at . The first Defendant is employed as: . (Position and Title) 2. (Institution) Name of second Defendant: at . The second Defendant is employed as: . (Position and Title) 3. (Institution) Name of third Defendant: at . The third Defendant is employed as: . (Position and Title) 4. (Institution) Name of fourth Defendant: at . The fourth Defendant is employed as: . (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: v. 1. Parties: 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 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 at your institution? G Yes G No G Yes G No b. Did you submit a request for administrative relief on Count I? 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 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 G Yes G No c. Did you appeal your request for relief on Count II to the highest level? d. If you did not submit or appeal a request for administrative relief at any level, briefly explain why you did not. . 4 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 G Yes G No c. Did you appeal your request for relief on Count III to the highest level? 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. 6