NOT FILED WITII LRC Rev. 1/04 DEPARTMENT OF CORRECTIONS INMATE GRIEVANCE INFORMATION FORM
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1 .. NOT FILED WITII LRC DEPARTMENT OF CORRECTIONS INMATE GRIEVANCE INFORMATION FORM Attachment I NA.l\.1E OF INSTITUTION DATE FILED GRIEVANT'S NAL\1E GRIEVANCE 'NLJMBER GRIEV ANT'S NUMBER UNIT/HOUSING ASSIGNMENT SUBJECT MATTER OF GRIEVANCES (Circle One) DUE DATES 1. Department Regulations 2. Canteen 3. Conflict with Staff Informal Resolution 4. Disciplinary Procedures 5. Food 6. Furloughs 7. Inmate Accounts 8. Housing Assignments Grievance Committee 9. Grievance Mechanism 10. Institutional Physical Conditions 11. Institutional Regulations 12. Job Assignments 13. Legal Services Warden/Administrative Review 14. Mail 15. Medical/Dental/Mental Health Services Notes/ETC. a. Access to Health Care Services b. Quality of Health Care c. Unfair or Discriminatory Treatment d. Safety or Sanitation 16. Personal Property 17. Permission to Marry 18. Recreation 19. Religious Services 20. Telephone Calls 21. Transfers 22. Treatment Program Assignments 23. Trips away from the facility 24. Visiting
2 NOT FILED \VITH LRC DEPARTMENT OF CORRECTIONS INMATE GRIEVANCE FORM Attachment II NAME ~ INSTITUTIONAL NUMBER UNIT/HOUSING ASSIGNMENT ~-.INSTITUTION GRIEVANCE NUMBER DATE RECEIVED BRIEF STATEMENT OF THE PROBLEM ACTION REQUESTED GRIEV ANT'S SIGNATURE DATE GRIEVANCEAIDE'S SIGNATURE/DATE INFORMAL RESOLUTION STAGE STAFF SIGNATURE DATE GRIEVANCE AIDE'S SIGNATURE I DATE I am or am not satisfied with this informal resolution to my grievance. (You have 5 working days to forw~d this form to the Grievance Coordinator to request a hearing.) GRIEV ANT'S SIGNATURE DATE
3 NOT FILED WITH LRC Attachment ill General FINDINGS AND RECOMMENDATIONS GRIEV ANCJE COMMITTEE ( ) I AM SATISFIED WITH THE RECOMMENDATION OF THE GRIEVANCE COMMITTEE COMMITTEE MEMBERS: ( ) I WISH TO APPEAL TIDS RECOMMENDATION TO THE WARDEN. (You have 3 working days to forward this form to the Warden.) GRIEVANT'S SIGNATURE/DATE CHAIRPERSON W.4..R.DEN'S REVIEW REVIEW AND DECISION DATE OF DECISION ( ) I AM SATISFIED WITH TIDS DECISION. ( ) I WISH TO APPEAL TIDS DECISION TO TrIE COMlV11.SSIONER. (You have 3 working days to forward this form to the Grievance Coordinator for the Ombudsman.) GRIEV ANTS SIGNATURE I DATE WARDEN'S SIGNATURE
4 NOT FILED WITH LRC Rev. 9/04 Attachment III Health Care FINDINGS AND RECOMMENDATIONS HEALTH CARE GRIEVANCE COMMITTEE ( ) I AM SATISFIED WITH THE RECOMMENDATION OF THE GRlEV ANCE COMMITTEE ( ) I WISH TO APPEAL TFJ:S RECOMMEl'-..TDATION FOR ADMINISTRATIVE REVIEW. (You have 3 working days to forward this form to the Grievance Coordi..TJ.ator.) GRIEV ANT'S SIGNATURE I DATE ADMINISTRATIVE REVIEW REVIEW AND DECISION DATE OF DECISION MEDICAL DIRECTOR
5 " t NOT FILED WITH LRC Attachment IV DEPARTMENT OF CORRECTIONS GRIEVANCE APPEAL FORM Please complete this form and attach it to your grievance. Explain why you are appealing this grievance to the Warden/ Commissioner I Health Care Administrative Review (circle appropriate one). GRIBVANT'SNA..ME GRIBVANT'S NUMBER GRIEV.A.NCENUMBER INSTITUTION I DATEAPPEALFILED GRIEV ANT'S SIGNATURE DATE
6 Not Filed with LRC - Attachment V Commonwealth of Kentucky Department of Corrections - Health Care Grievance Process Authorization for Release of Patient Information The undersigned patient authorizes as indicated below the disclosure of the patient's health information: Name of Patient Imnate Number All dates Date(s) oftreatment to be Released Records and information to be released from: Department of Corrections and/ or Eastern Kentucky Correctional Complex Purpose of Disclosure: Inmate Grievance Process Records and information to be released to: Any Corrections staff, health care provider, or other individual who is involved in the grievance process for the handling of patient's health care grievance including review by an outside health care professional (if used in the grievance process) D Grievance aides are to be excluded from this authorization if box is checked. lnfonnation to be disclosed includes: D Admission Records D Discharge Instructions D Radiology D Laboratory 0 Medication Records 0 Progress Notes D Physical Therapy Notes 0 Dental Records 0 Optometry Records 0 Physician Orders/Prescriptions 0 History and Physical 0 Medical Records from Outside Providers D Mental Health Records 0 Complete Medical Records D Other (Specify): ***I understand that the health records may contain infonnation relating to testing, diagnosis, and/or treatment of hepatitis, HIV/AIDS, sexually transmitted diseases, sickle cell disease, and drug and/or alcohol abuse. I authorize the :release of these records, if they are located in my health records, unless I have specifically marked out that type ofrecord from this paragraph.*** ***I understand that the health records may contain information that may relate to mentai health, but are also medical in nature including but not limited to medication prescriptions and monitoring, mental status, functional status, and symptoms. I authorize the release of these records. I understand that this authorization does not include the separate mental health section of my medical record, unless it is marked specifically above. *** REVOCATION AND TIME LIMITATION: I understand that this authorization may be revoked in writing at anytime, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire one year from the date of signature. REDISCLOSURE: The grievance process is confidential and disclosure of information gat'ftered in the process is prohibited from redisclosure outside of the grievance process without an authorization from the patient/inmate. Records pertaining to drug and/or 8.lcohol abuse treannent are prohibited from redisclosure pursuant to 42 C.F.R. Part 2 unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. I have read or been infonned of the contents of this aufaorization and ah areas were properly completed prior to my signature and I am aware that this form is not required as a condition for treatment The facility, its employees, and agents are hereby released from any legal responsibility or liability for disclosure of the above infonnation to rhe extent indicated and authorized herein. Signature (Patient or Legal Representative and Title) Date Signature of Witness (if Patient signs with mark) Date
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