Free Letter - District Court of Delaware - Delaware

Case1:05-cv-00037-SLR D0cument19-2 Filed 07/07/2005 Page10f4_ ;e—
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_ — Cass l¤°5·¤V·°0°37·SL"* ¤cP‘EFél§J·i%i'é &%e?ecil¤Ei'estQZ;’P7’20°5 Page 2 Bia; IO!27/2004
Smyrna Landing Road
SMYRNA DE, 19977
- Phone No. 302-653-9261
9 9 9 GRIEVANCEREPORT 9 9 9
Offender Name :SAMUEl.. HARRY L SBI# : 00201360 Institution ; DCC B. °9 99
Grievance # ; 7953 Grievance Date : tO/O?/2004 Category : Individual
status ; Unresolved Resolution statue: Re=·»¤l- Date r
Grievance Type: Health Issue (Medical) Incident Date : 09/05/2004 Incident Time :
IGC : Merson, Llse M Housing Location : Bldg 21, Lower, Tier B, Cell 9, Bottom _g'_ ¤
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Description of Complaint; I requested to get treatment from the dentist by putting a sick call slip in the sick call box on Qi?/O4. _
Sgt. Sullivan gave me sick call form after I reported my dental problem to him. I put in two other “"9
y sick calls for this matter and my problem is filling is out and I got a big hole in my tooth if not ,_
g treated I will lose my tooth. 2. Also warden foiware a letter to have braces to fix my front teeth. lt's
g been years the dentist didn't call yet. The reason I am submitting this grievance is because it has -
been a month and I haven't seen the dentist in a month sence my request. The dentist assistant
seen me after a month but no treatment now it been another month and no treatment. Q
Remedy Requested : To have my toth till in by the dentist soon before I loose my tooth and have to have my front teeth i
braced like warden said he notified the dentist supervisor to take action. "
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Medical rzievance : YES Date Received by Medical Unit : 10»{22}l2004 I
Investigation Sent ; 10l22/2004 Investigation Sent To : Wolken, Gina _ g
Grievance Amount: __ _ g _ [ _ g __
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Page 1 of 2

D Case 1:05-cv-00037-SLR Document 19-2 Filed 07/07/2005 Page 3 of 4
.- DCC Delaware Correctional Center Date: 10/27/2004
Smyrna Landing Road
SMYRNA DE, 19977
Phone No. 302-653-9261
INFORMAL RESOLUTION
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Offender M:,v‘-·l: QMQQEL, HARRY L SBW ; 00201360 Institution 1 DCC "
Grievance # : Teeqi Grievance Date : 10/07/2004 Category ; individual
status ; Llnresolved Resolution status: lflmalé Status ¢
I Grievance Tvpe;§%illn issue (Medical) Incident Date : 09/05/2004 Incident Time :
IGC I gg 1 ’l‘lg€_[$¤li· USB M {__ T __ using Location ;Bldg 21, Lower. Tier B, Cell 9. B¤ll0¤"l ·
I DD D D D D DD AL R¤S<>wr .o ... . DD i it D . DD C DD ic D D D D I
-` Investigator Name 1 F/0lken,Glna in A Dato of Report IO/22/2004 Q
Investigation Reoortz
Reason for Referring: _`
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G \/e *i Offender'?. Signature:
Date :
Witness (Officer) :
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ll Page 2 of 2

Case1:05-cv-00037-SLR D0cument19—2 Filed 07/07/2005 Page4of4 A
Grievance Appeal Form
This must be completed and returned to the IGC within receipt of the Warden/Designee Decision
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ei Grievant: Meta- ry §qimL{&/ 5m#; 0020/3éO
Housing Unit: IQ C 3 lj (jasctt; ja`
Date: Tuesday, February 15,2005 Due Date: Friday, February 19, 2005
This fomt is to be used _Qp_Iy in the event of a decision appeal. Please specify the reason for the appeal in
the space below.
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