DEPARTMENT OF CORRECTIONS Division of Adult Institutions WISCONSIN DOC-400 (Rev. 4/2015)

Chap Administrative Code

er DOC 303.32 & 310

OFFENDER COMPLAINT 1 INSTRUCTIONS: SEE REVERSE SIDE TO BE COMPLETED BY ICE ONLY

I OFFENDER NAME (if group complaint, enter name of spokesperson)

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DOC NUMBER

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DOC COMPLAINT FILE NU61BER

DATE COMPLAINT RECEIVED

FACILITY NAME çJ

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DATE OF INCIDENT OR DENIAL OF REQUEST

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STATE YOUR COMPLAINT

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NAMES OF PEOPLE WHO HAVE INFMATION ABOUT THI COMPLAINT ci 7

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SIGNATURE OF OFFENDER

e, / SPOKESPERSON

--7 DATE SIGNED

DISTRIBUTION: Original — ICE will acknowledge your complaint within 5 working days of the date of receipt.

Scott Walker Governor

State of Wisconsin Department of Corrections

Mailing Address

COLUMBIA CORRECTIO AL INSTITUTION 2925 COLUMBIA DRIVE

P. 0. BOX 950

PORTAGE, WI 53901-0950

ICE RETURN LETTER

09/20/201 6

MORGAN, RAYNELL D. - #279380 UNIT: H6BL — 491.. COLUMBIA CORRECTIONAL INSTITUTION

PO Box 900 PORTAGE, WI 53901-0900

The submission received on 09/19/2016 is not accepted. - Before this complaint is accepted, you need to attempt to resolve the issue by contacting Dr. Landers, PSU

Supervisor [DOC 310.09(4)1.

- Other, see comments below. Please send this Return Letter to Dr. Landers, PSU Supervisor, along with your Inmate Complain or a DOC-643, "Inmate Request" explaining the issue you want to resolve. Please allow the staff member enou h time to reply (at

least 10 working days after CCI Staff receive your request for a response).

If you feel the staff member does not address or resolve the issue, you may resubmit your lnmat Complaint to the Inmate Complaint Office. When resubmitting, please include the Original Complaint AND this R turn Letter.

WHETHER YOU RECEIVE A REPLY OR NOT, you have 14 working days from the date of this eturn Letter to

resubmit your Inmate Complaint.

TO: Dr. Landers, PSU Supervisor FROM: Inmate Complaint Office

1)Please document your response or action taken on this letter, date/sign.

2) Return this letter to inmate.

Sincerely,

LTyLr c9

M. Leiser Institution Complaint Examiner Program Assistant

Enclosure(s)

Institution omplaint Examiner's Office Page 1 of . 1

*" ICRS CONFIDENTIAL ** Print Date: September 20, 2016

FOLD THIS REQUEST OVER TO THE LINE BELOW SO THAT INFORMATION REMAINS CONFIDENT AL DO NOT USE THIS FORM IF YOUR MENTAL HEALTH NEED IS AN EMERGENCY, SPEAK TO STAFF DIRECTLY. IN THE LINED AREA BELOW, WRITE DOWN WHAT YOUR REQUEST IS ABOUT. BE AS SPECIFIC AS YOU CAN.

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I WOULD LIKE TO SE PSYCHOLOGY STAFF CI I DO NOT NEED TO SEE PSYCHOLOGY STAFF 60

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0 NOT WRITE BELOW THIS LINE — TO BE FILLED IN BY STAFF ONLY _ _ _

lot • TRIAGED BY

PEW

NOTES (IFINI.EEDED)

DATE RECEIVED ACTION

cp% STAFF INITIALS

HS Direct Response El Delegate to

0 Refer to PSU (routine) 0 Other (specify in notes below)

STAFF SIGNATURE \ DATE SIGNED

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PRINT STAFF NAME

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DEPARTMENT OF CORRECTION Division of Adult Institutions DOC-3035B (Rev. 8/2014)

• USE THIS FORM TO COMMUNICATE WITH THE PSYCHOLOGICAL SERVICES UNIT (PSU). • USE THE BLUE DOC-3035 HEALTH SERVICE REQUEST IF YOUR REQUEST IS RELATED TO PSYCHIATRIC

MEDICATION OR PSYCHIATRIC SERVICES • PLACE ALL PAGES OF COMPLETED FORM IN THE DESIGNATED COLLECTION LOCATION. • PRINT CLEARLY

LAST NAME ' DOC NUMBER

TODAY'S DATE

REQUEST FOR:

O REQUEST FOR PSU RECORD REVIEW 0 OTHER:

O PSYCHOLOGICAL SERVICES

0 INFORMATION 0 REQUEST FOR COPIES FROM PSU RECORD (List rec

PSYCHOLOGICAL SERVICE REQUEST

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FIRST NAME

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RESPONSE

El A psychology apPcitment is scheduled for the following time frame:

Li Your request has bee referred to the Psychiatrist within the Health Service Unit

0 Your request has been referred to the Health Services Unit for medical issues _ _ 0 Refer for a record review *ointment or for copies only. (Must be processed within 30 days of request)

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PSI.) Pe:ord , lrute Corresporidei .ice Section

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N I ENTRE VISTA OFFENDER NAME NOMBRE DEL/LA OFENSOR(A)

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WORK ASSIGNMENT ASIGNACION DE TRABAJO

I I Interview Entrevista Information lnformacion

STATE REASON FOR INTERVIEW OR SPECIFY INFORMATION REQUESTED INDIQUE LA RAZON PARA LA ENTRE VISTA 0 ESPECIFIQUE LA INFORMACION QUI

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DISPOSITION OF REQUEST DISPO$ICION DE LA SOLICITUD Vec 5e Ske COe

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You Will Be Interviewed Date: Time: Usted sera entrevistado Fecha: Hora:

Information to Follow lnformacion Sera Pro veida I I Request Referred To:

Solicitud Refereida A:

Information/Comment: InformacionlComentario:

Signed Firmado Department Departamen o

WISCONSIN DEPARTMENT OF CORRECTIONS Division of Adult Institutions DOC-643 (Rev. 9/2011)

INTERVIEW/INFORMATION REQUEST

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