ONE STAPLE ONLY
W. Va. Division of Corrections Inmate Grievance Form Grievance No. ______-________-______-______________________________________ _____________ ______________
Inmate Name DOC # Date of Grievance
State Nature of Grievance / Issue to be addressed (Note 1 issue per grievance be concise file with Unit Manager NO WRITING ON BACK):
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Relief Sought (state what you want):______________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________ (The inmate may attach 1 8.5 x 11 sheet if necessary at this level only)
Inmate's Signature
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Unit Manager's Response (attach additional sheet if needed)
Accepted_____ Rejected____ Reason for rejection:___________________________________________ Date:__________
Response on Merits if accepted:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________
Signature
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Resolved:___________ (if so initial and give copy to unit manger) Appealed to Warden/Administrator ________(initial) Date:________
If no response at initial level is included the inmate certifies that he/she has tendered this grievance as indicated above and no response has been issued at that level within the time frames set forth in Policy Directive 335.00
_______________________________________ _________________________
Inmate's Signature Date
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Action by Warden/Administrator:
Accepted_____ Rejected____ Reason for rejection:___________________________________________ Date:__________
Response on Merits if accepted: __ Remand to Unit for further action __ Affirm unit and/or deny grievance __ Grant the Grievance as specified
Comments___________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____________________________________ ___________ (Attach additional sheet if necessary)
Warden/Administrator's SignatureDate
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Resolved:___________ (if so initial and give copy to unit manger) Appealed to Commissioner ________(initial)
If no response at warden'sl level is included, the inmate certifies that he/she has tendered this grievance as indicated above and no response has been issued at that level within the time frames set forth in Policy Directive 335.00
_______________________________________ _________________________
Inmate's Signature Date
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Action by Commissioner:
Accepted_____ Rejected____ Reason for rejection:___________________________________________ Date:__________
Response on Merits if accepted: __ Affirm Warden/Administrator and deny grievance (Affix final stamp) ___Other, memo attached.
Grievance Log
Facility:_____________
Unit:___________________ Calendar Year:______________
Seq.# | Doc# | Inmate | Date Filed | Issue | Resp. Date |
W. Va. Code R. § 90-9-8