Lynch v. Doe et al

Filing 34

OPINION AND ORDER re: 24 MOTION to Dismiss . MOTION to Dismiss for Lack of Jurisdiction . filed by John Doe, Jane Doe. Defendants' motion to dismiss is GRANTED. Plaintiff is granted leave to file an amended complaint . which must be filed by April 15, 2016, using the Amended Complaint form attached hereto. The completed Amended Complaint form must be mailed to the Pro Se Clerk at the United States Courthouse, 300 Quarropas Street, White Plains, New York 10601. If plaintiff does not file an amended complaint by that date, this case will be dismissed with prejudice. The Clerk is instructed to terminate the motion. (Doc. 24). The Court certifies pursuant to 28 U.S.C. § 1915(a)(3) that any appeal from this order would not be taken in good faith, and therefore in forma pauperis status is denied for the purpose of an appeal. See Coppedge v. United States, 369 U.S. 438, 444-45 (1962). (Signed by Judge Vincent L. Briccetti on 2/29/2016) (rj)Copies Mailed By Chambers.

____________

UNITED STATES DISTRICT COT. RT
SOUTHERN DISTRICT OF NEW YORK
x

USDS SDNY
DOCUMENT
ELECTRON1cy FILED
DOC#:
jDATE FILED:

RENAY LYNCH,
Plaintiff.
OPINION AND ORDER
14CV6919(VB)
JANE DOE CORRECTIONAL OFFICER
BLUE. JANE DOE CORRECTIONAL
OFFICER VvAXTER. JOHN DOE
CORRECTIONAL OFFICER ASKEW,
Defendants.
Briccetti, J.:
Plaintiff Renay Lynch, an inmate proceeding p se, brings this Section 1983 civil rights
action, alleging defendants were deliberately indifferent to her safety and her medical needs in
1
violation of the Eighth Amendment. Defendants Blue, Waxter, and Asquith are Correctional

Officers employed by the New York State Department of Corrections and Community
Supervision at Bedford Hills Correctional Facility (“Bedford Hills”) in Bedford Hills, New York.
Defendants move to dismiss the complaint under Rule 12(b)(6). (Doe. #26).
For the reasons set forth below, defendants’ motion is GRANTED.
The Court has jurisdiction under 28 U.S.C. § 1331.
BACKGROUND

The following facts are drawn from the complaint and documents on which plaintiff
relied in bringing suit. DiFolco v. MSNBC Cable L.L.C., 622 F.3d 104. 111 (2d Cir. 2010)
(noting the court may considei documents integral to the complaint if it is clear on the record that
no dispute exists regarding the authenticity or accuracy of the documents).

Plaintiff incorrectly spelled Officer Asquith’s name as “Askew” in her complaint. The
Court refers to Officer Asquith by the correct spelling of his name in this opinion.

At all relevant times, plaintiffwas incarcerated at Bedford Hills. On February 20, 2014,
she and several other inmates were being transported in a van back to Bedford Hills from a
2
medical trip to Mt. Vernon Hospital. Officer Asquith drove, Officer Blue was in the front
passenger seat, and Officer Waxter sat in the back of the van with the inmates. Plaintiff alleges
Officers Asquith and Blue had “loud music blasting” while they were “traveling in a fast moving
van on a dark highway at 7:30 p.m. at night.” (Compl. ¶ 2). Plaintiff alleges the van was
traveling 65 to 70 miles per hour and the officers listened to music because they were “laid
back[,] trying to enjoy themselves and block the inmates out.” (P1.’ s Opp. at 6).
Suddenly, one of the inmates began having a seizure, “causing chaos in the vehicle.”
(Compl.

¶ 2).

Officer Waxter “panicked” (Pl.’s Opp. at 1), and “asked [plaintiff] to get up out

[of her] seat and move.
(Compl.

¶ 2).

.

.

so [Officer Waxter] could help [the inmate] having seizures.”

Plaintiff, shackled with leg irons and chains around her waist, got up and was

“thrown to [the] front of [the] van and then landed in [the] door well.” Id. Plaintiff contends she
injured her right hand, which was bandaged and in a sling from a recent operation. She also
alleges she hurt her back and the right side of her body, and her “left index finger [was] busted
open” and bleeding. Id. ¶J 2, 3.
Defendants brought the inmate who had the seizure to Westchester Medical Center.

Plaintiff alleges defendants saw her “bleeding as she and the other inmates stood on the
sidewalk” (P1.’ s Opp. at 6), but they “refused to have [her] seen [by medical personnel] at
Westchester Med ica1.’ (Compl,

¶ 2),

In plaintiff’s administrative grievance attached to her complaint, she states Officer Blue
pressed on her handcuffs to try to cut her skin while they were in the hospital. But plaintiff does
not refer to this incident in her complaint or anywhere else in her filings. Therefore, even
liberally construed, the Court finds plaintiff is not attempting to allege a claim based on this
handcuffing incident.
2

After arriving back at Bedford Hills, plaintiff alleges Officer Waxter “refused to report
[her] injuries or file an incident report” in an attempt to cover up the incident. (Compl. ¶ 2).
Plaintiff concedes nurses in the medical department treated her injuries that same day.
On February 21. 2014. plaintiff filed an inmate grievance complaint based on Officer
\Vaxter’s refusal to tile an incident report about plaintiffs injuries. The superintendent denied
3
plaintiffs grievance, and plaintiff appealed.
Plaintiff alleges she had a second operation on her finger on June 25. 2014, and her right
thumb is now deformed. On August 25, 2014, plaintiff filed her complaint (Doe. #1), and on
June 30, 2015, defendants moved to dismiss for failure to state a claim pursuant to Rule 12(b)(6).
(Doe. #24).
DISCUSSI ON

1.

Legal Standard
A.

Rule l2(b)(6) Standard

In deciding a Rule l2(b)(6) motion, the Court evaluates the sufficiency of the operative
complaint under the “two-pronged approach” articulated by the Supreme Court in Ashcroft
v. lqbal, 556 U.S. 662, 679 (2009). First, plaintitTs legal conclusions and “{t]hreadbare recitals
of the elements of a cause of action, supported by mere conclusory statements,” are not entitled

The Prison Reform Litigation Act states in relevant part: ‘No action shall be brought with
respect to prison conditions under section 1983 of this title, or any other Federal law, by a
prisoner confined in an jail, prison, or other correctional facility until such administrative
remedies as are available are exhausted.” 42 [S.C. I 997e(a), This exhaustion requirement
“applies to all inmate suits about prison life. hether they involve general circumstances or
particular episodes. and whether they allege excessive force or some other wrong.” Porter v.
Nussle, 534 [.5. 516. 532 (2002). Although defendants argue plaintiffs administrative
grievance was not fully exhausted. the Court need not decide whether plaintiff fully exhausted
her grievances because. as discussed below, the Court dismisses plaintiffs claims on substantive
grounds.

to the assumption of truth and are thus not sufficient to withstand a

motion to

dismiss. Id. at 678:

Hayden v. Paterson. 594 F.3d 150. 1 61 (2d Cir. 201 0). Second. [wjhen there are well-pleaded
factual allegations, a court should assume their veracity and then determine whether they
plausibh. ive rise to an entitlement to relief. Ashcroft v. lqbal. 556 U.S. at 679.

To survive a Rule 12(b)(6) motion, the allegations in the complaint must meet a standard
of “plausibility.” Id. at 678; Bell At!. Corp. v. Twom, 550 U.S. 544, 564 (2007). A claim is
facially plausible “when the plaintiff pleads factual content that allows the court to draw the
reasonable inference that the defendant is liable for the misconduct alleged.” Ashcroft v. lgbal,
556 U.S. at 678. “The plausibility standard is not akin to a ‘probability requirement,’ but it asks
for more than a sheer possibility that a defendant has acted unlawfully.” j.
The Court must liberally construe submissions of se litigants, and interpret them “to
raise the strongest arguments that they suggest.” Triestman v. Fed. Bureau of Prisons, 470 F.3d
471. 474 (2d Cir. 2006) (per curiarn) (internal quotation marks and citation omitted). Applying
the pleading rules permissively is particularly appropriate when, as here, a p se plaintiff alleges
civil rights violations. See Sealed Plaintiff v. Sealed Defendant, 537 F.3d 185, 191 (2d Cir.
2008). “Even in a

se case. however.., threadbare recitals of the elements of a cause of

action. supported by mere conclusory statements, do not suffice.” Chavis v. Chappius, 618 F.3d

162, 170 (2d Cir. 2010) (internal quotation marks and citation omitted). Nor may the Court
“invent factual allegations” plaintiff has not pleaded. j.

4

II.

Eighth Amendment Claims
Construed liberally, plaintiffs complaint alleges defendants violated her Eighth

Amendment rights by (i) failing to protect her safety in the van and (ii) failing to provide medical
treatment once she became injured. The Court addresses each theory of liability in turn.
A.

Safe Conditions of Confinement

The Eighth Amendment requires prison conditions to be at least ‘humane.” Gaston v.
Coughlin. 219 F.3d 156. 164 (2d Cir. 2001)

(quoting

Farmer v. Brennan. 511 U.S. 825. 832

(1994)). To adequately allege an Eighth Amendment violation, an inmate must satisfy objective
and subjective elements of a two-pronged test.
First. under the objective prong. an inmate must allege facts showing she was denied “the
minimal civilized measure of life’s necessities.” Farmer v. Brennan, 511 U.S. at 834 (quoting
Rhodes v. Chapman, 452 U.S. 337, 346 (1981)). When, as here, the claim is based on an alleged
failure to prevent harm or provide safety. the inmate must show she “is incarcerated under
conditions posing a substantial risk of serious harm.” Id.
Second, under the subjective prong, an inmate must allege facts showing officials acted
with “deliberate indifference” to the inmate’s “health or safety.” Farmer v. Brennan. 511 U.S. at
834. A correctional officer acts with deliberate indifference only when he “has knowledge that
an inmate faces a substantial risk of serious harm and he disregards that risk by failing to take
reasonable measures to abate the harm.” Haves v. New York City Dep’t of Corrs.. 84 F.3d 614.
620 2d Cir. 1 996L A prison official

both be aware of facts from which the inference

could be dra\n that a substantial risk of serious harm exists, and he must also draw the
inference.’ Cuoco v. Moritsugu. 222 F,3d 99. 107 (2d Cir. 2000) (quoting Farmer v. Brennan.
511 U.S. at 837).

Claims brought under Section 1983 must allege the personal involvement of each
defendant. Grullon v. City of\ew Haven. 720 F.3d 133. 138 (2d Cir. 2013). “Conclusorv
accusations regarding a defendant’s personal involvement in the alleged violation, standing
alone, are not sufficient.” Brown v. Doe, 2014 WL 5461815. at *8 (S.D.N.Y. Oct. 28. 2014)
(citation omitted). appeal dismissed (Feb. 17. 2015).
Officers Asguith and Blue
Defendants argue plaintiffs Eighth Amendment claim based on Officers Asquiths and
Blue’s failure to protect her in the van must be dismissed because plaintiff failed to allege these
defendants were personally involved in any failure to provide for plaintiffs safety.
The Court agrees.

Officers Asquith and Blue were in the front seat of the van while plaintiff was in the
back. Plaintiff alleges she fell and was injured while Officers Asquith and Blue were playing
music too loudly and while Officer Asquith was driving the van on a dark highway at night.
Even liberally construed, these facts do not plausibly allege Officers Asquith and Blue were
personally involved in any violation of plaintiffs constitutional rights arising from plaintiffs
injury in the van. Plaintiff has not alleged either officer in the front seat was aare plaintiff was
switching seats in the back of the van. Nor has plaintiff alleged sufficient facts to support an
5
inference Officer Asquith was driving recklessly or in deliberate disregard for plaintiffs safety.

Plaintiffwill be provided with copies of all unpublished opinions cited in this decision.
Sec Lebren v. Sanders. 557 F 3d 76. 79 2d Cir, 2009).

Although courts in other circuits have held allegations of reckless driving, combined with
failure to provide seatbelts. may be sufficient to survive a motion to dismiss, see Fouch v. D.C..
a
10 F. Supp. 3d 45, 505l (D.D.C. 2014) (collecting cases). the Second Circuit has yet to squarely
address the issue. In any event, plaintiff here has not alleged sufficient facts giving rise to an
inference Officer Asquith was driving recklessly. Cf. Rogers v. Boatright, 709 F.3d 403, 406
(5th Cir. 2013) (plaintiff alleged defendant was ‘darting in and out of traffic at high speeds”).
Plaintiffs onl allegations as to Officer Asquith’s driving are (i) he “refused to stop the vehicle
6

Accordingly, plaintiffs complaint fails to allege Officers Asquith and Blue were
personally involved in violating plaintiffs constitutional rights based on the failure to ensure her
safety in the van.
2.

Officer \Vaxter

Unlike Officers Asquith and Blue. Officer Waxter was personally involved because she
was in the back of the van with plaintiff and instructed her to change seats. leading to plaintiffs
injuries. However, even liberally construed, plaintiffs allegations fail to satisfy the objective
and subjective prongs of an Eighth Amendment violation.
As to the objective element, there is no definitive test to determine when a condition is
sufficiently serious. The Second Circuit has held “the failure to provide a seatbelt is not, in
itself sufliciently serious to constitute an Eighth Amendment violation.” Jabbar v. Fischer, 683
F.3d 54. 58 (2d Cir. 2012) (quotations omitted). In Jabbar, a bus transporting the plaintiff made
a forceful turn and he hit his head, knocking him unconscious. Id. at 56. In affirming the district
court’s dismissal of the plaintiffs claim, the Second Circuit held that a vehicle’s lack of
seatbelts, without more, is “reasonable.” Id. at 58; see also Carrasguillo v. City of New York,
324 F. Supp. 2d at 436 (“Auto accidents do not, in and of themselves, give rise to federal causes

of action.”).
The case at hand is a closer call than Jabbar because here, in addition to plaintiffs not
wearing a scatbelt. Officer Waxter allegedly ordered plaintiff to change seats. Construed

with loud music blasting” (Compl. ¶ 2), and (ii) the van was “going 65 to 70 mph.” (PI.’s Opp. at
1). Even assuming Officer Asquith was driving above the speed limit, “this adds nothing of legal
significance to [pjlaintiff s claim” because without more, “allegations of a public official driving
too fast for the road conditions are grounded in negligence.” Carrasquillo v. City of New York,
324 F. Supp. 2d 428. 436 (S.D.N.Y. 2004) (quotations and alterations omitted).
7

liberally, plaintiff alleges Officer Waxter created a condition that posed a greater risk of harm to
plaintiff than merely not having a seatbelt.
Nevertheless, having considered the application of Jabbar. the Court concludes, based on
the allegations of the complaint, that Officer Waxter did not create a condition that posed a
substantial or excessive risk of serious harm to plaintiffs safety. The magnitude of the increase
in risk of injury by momentarily changing seats. compared with merely not wearing a seatbelt. is
slight, and not unreasonable because it was based on Officer Waxter’s need to access an inmate
experiencing a seizure. See.

Williams v. City of New York, 2005 WL 2862007, at *2

(holding the Eighth Amendment proscription against cruel and unusual punishment “does not
cover vehicular accidents that expose a plaintiff to the risk of injury”) (quoting Carrasquillo, 324
F. Supp. 2d at 437).
Moreover, even assuming plaintiff did adequately allege Officer Waxter created a
condition that posed a substantial risk of serious harm, plaintiff has failed to allege Officer
Waxter knew of and disregarded the risk in satisfaction of the subjective prong of the deliberate
indifference test.
Plaintiff alleges Officer Waxter, in a moment of “chaos” (Compl.

¶ 2),

“panicked,” and

directed plaintiff to move away from the inmate having a seizure. (Pl.’s Opp. at I). Plaintiffs
allegations do not support an inference Officer Waxter knew it would be dangerous for plaintiff
to move aav from the inmate having a seizure, and then disregarded that risk.

f.

Allah v.

Goord, $05 F. Supp. 2d 265. 276 (S.D.N,Y. 2005) (holding subjective prong satisfied because

defendant driver stopped short, injuring wheelchair-bound plaintiff then, after repositioning the
plaintiff, stopped short again. “in complete disregard for plaintifFs interests or safety”) .At most,
plaintiff has plausibly alleged Officer Waxter did not consider the risk to plaintifrs safety in

8

ordering her to change seats because the officer panicked in a moment of chaos. Those
allegations may give risc to a claim of negligence, but are not actionable under the Constitution.
See White v. City of New York. 2011 WL 5873392, at *1 (S.D.N.Y. Nov. 22, 2011).
According1, because plaintiff thiled plausibly to allege that Officer Waxter created an
excessive risk of harm to plaintiffs safety and consciously disregarded that risk, her Eighth
Amendment claim based on her injury in the van is dismissed.
B.

Failure to Provide Medical Treatment

After plaintiff v as injured, she alleges defendants were deliberately indifferent to her
serious medical needs. Defendants argue plaintiff failed to state an Eighth Amendment claim
because she received treatment for her injuries later that day.
The Court agrees.
To assert a viable Eighth Amendment claim in the context of inadequate medical care,
plaintiff must allege “acts or omissions sufficiently harmful to evidence deliberate indifference to
serious medical needs.” Estelle v. Gamble, 429 U.S. 97, 106 (1976). Similar to liability based
on failure to provide safe conditions of confinement, this test has both an objective and a
subjective component: plaintiff must plead facts showing (i) the alleged deprivation of medical
care is “sufficiently serious.” and (ii) the officials in question acted with a “sufficiently culpable
state of mind.” Salahuddin v. Goord, 467 F.3d 263, 279-80 (2d Cir. 2006).
To satisfy the objective component. a condition is sufficiently serious

if it may cause

“death. deeeneration. or extreme pain,” Johnson v. Wright. 412 F3d 398. 403 (2d Cir. 2005)
(quoting

134 F.3d 104, 108 (2d Cir, 1998)), or if “the failure to treat

[the] condition could result in further significant injury or the unnecessar and wanton infliction

9

of pain.” Harrison v. Barkley, 219 F.3d 132. 136 (2d Cir. 2000) (quoting Chance v. Armstrong,
143 F.3d 698. 702 (2d Cir. 1998)).
To satisfy the subjective component. a plaintiff must allege the defendant had a mental
state akin to recklessness, which requires that the charged official act[edj or fail[ed] to act while
actually aware of a substantial risk that serious inmate harm will result.” Salahuddin v. Goord,
467 F.3d at 280

(citing

Farmer v. Brennan. 511 U.S. 825. 836-37 (1994)). For example. “a

deliberate indifference claim can lie where prison officials deliberately ignore the medical
recommendations of a prisoner’s treating physicians.” Johnson v. Wright, 412 F.3d at 404
(citing

Gill v. Moone

,

824 F.2d 192, 196 (2d Cir. 1987)).

here, plaintiff alleges defendants “refused to have [her] seen at Westchester Medical
[Center]” even though her finger was bleeding. (Compl.

¶ 2).

But plaintiff concedes Bedford

Hills’s medical staff treated her when she returned to Bedford Hills. Liberally construed, her
allegations are that she should have been treated by the hospital’s staff instead of by prison
nurses. and her treatment was delayed because she was

not treated at

the hospital.

However, plaintiff fails to allege the prison medical staff’s treatment was inadequate, that
the delay in treatment led to a serious medical condition,

or

that defendants acted with the

requisite deliberate indifference.
Plaintiff’s preference to he treated by doctors at the Westchester Medical Center instead
of the prison medical staff does not constitute a constitutional claim, especially when. as here,
plaintiff does not allege the prison medical staff’s treatment of her injuries was inadequate. See
Chancev. Armstron2. 143 F3d 698. 703 (2d Cir. 1998) (“It is ell-established that mere
disagreement over the proper treatment does not create a constitutional claim. So long as the

10

treatment given is adequate, the fact that a prisoner might prefer a different treatment does not
give rise to an Eighth Amendment violation.”).
Similarly, the delay plaintiff faced before receiving treatment cannot form the basis of a
constitutional claim. Under some circumstances, prolonged delays in treatment can support an
inference of deliberate indifference. Hathawayv, Coughlin, 37 F.3d 63,67 (2d Cir. 1994) (ajury
could infer deliberate indifference based on a tvo-year delay): see also Smith v. Carpenter. 316
F.3d 178. 186 (2d Cir. 2003) (a deIa in treatment of”an otherwise insignificant wound” could
conceivably create a substantial risk of injury if the wound became infected due to the delay).
But plaintiff has not alleged any fticts as to how the delay between the hospital and the prison
created or worsened her medical conditions. Even liberally construed, the lapse in treatment here
is rninor and inconsequential.” Id.
More fundamentally, the complaint contains no allegations indicating any of the
defendants were actually aware of a substantial risk plaintiff would experience harm if she
waited to be seen by the prison medical staff, and then disregarded that risk.
Accordingly. plaintiff’s claim based on defendants’ failure to provide medical treatment
is dismissed.
6
Ill.

State Law Claims
Construed liberally, plaintiffs complaint arguably contains state law tort claims for

negligence. Having dismissed plaintiffs federal claims, the Court declines to exercise

To the extent plaintiffs complaint articulates a claim based on defendants’ failure to file
an incident report upon returning to Bedtbrd Hills. that claim is also dismissed. Carrasguillo v.
to
City of New York. 324 F. Supp. 2d at 436 (“Individuals do not have a constitutional right
have the government investigate the cause of such an injury.”).
.

11

.

.

supplemental jurisdiction over any state law claims in plaintiffs complaint pursuant to 28 U.S.C.
S

1367(e)(3).

IV.

Leave to Amend
The Court v ill, however allow plaintiff to amend her complaint with respect to her claim

arising from defendants alleged failure to provide for her safety in the van. District courts
“should not dismiss

[ se complaints] without granting leave to amend at least once when a

liberal reading of the complaint gives any indication that a valid claim might be stated.” Cuoco
v. Moritsuu. 222 F.3d 99. 112 (2d Cir.2000) (quoting Gomez v. USAA Fed. Say. Bank, 171
F.3d 794, 795 (2d Cir.1999)).
Plaintiff is directed to state in her amended complaint (i) whether and how Officer
Asquith was driving recklessly. causing plaintiff to fall into the door well; (ii) whether and how
Officer Blue was involved in Officer Asquith’s reckless driving; and (iii) whether and how
Officer Waxter created a condition that posed a substantial or excessive risk to plaintiffs safety,
and then disregarded that risk.
Plaintiff is reminded that any factual allegation in the amended complaint must be true to
the best of her knowledge, information, and belief. See Fed. R. Civ. P. 1 l(b)(3). Because the
amended complaint will completely replace the amended complaint, plaintiff should include in

the amended complaint all information necessary to state a claim. Plaintiff is directed to
complete the Amended Complaint form attached to this

Opinion

and Order.

Plaintiff is further directed to attach to her amended complaint any grievances she filed
with respect to the incident in the van, as well as all evidence relating to her efforts to exhaust
her administrative remedies prior to commencing this action.
Plaintiff is not granted leave to file an amended complaint with respect to her claims
related to the alleged failure to treat her injuries. The complaint and plaintiffs opposition to
defendants’ motion to dismiss

even liberally construed

—

contain no allegations suggesting she

has a valid claim that she has merely “inadequately or inartfully pleaded” and therefore should
“be given a chance to reframe.” Cuoco v. Moritsugu. 222 F.3d at 112. Thus, re-pleading
plaintiffs failure to treat claim would be futile because plaintiffs claims suffer from substantive
deficiencies that cannot be cured.
CONCLUSION
Defendants motion to dismiss is GRANTED.
Plaintiff is granted leave to file an amended complaint. which must be filed by April 15,

20 1 6. using the Amended Complaint form attached hereto. The completed Amended Complaint
form must be mailed to the Pro Sc Clerk at the United States Courthouse, 300 Quarropas Street,
White Plains, New York 10601. If plaintiff does not file an amended complaint by that date, this
case will be dismissed with prejudice.
The Clerk is instructed to terminate the motton. tDoe. 24).

13

The Court certifies pursuant to 28 U.S.C.

§

1915(a)(3) that any appeal from this order

would not be taken in good faith, and therefore in forma pguperis status is denied for the purpose
of an appeal. See Coppedge v. United States. 369 U.S. 438, 444.-45 (1962).
Dated: February 29. 2016
White Plains. \
SO ORDERED:

Vincent L. Briccetti
United States District Judge

‘4

_______________________________________
___________________________________________________________________________________
___________________________________________________________

________

_______
______
____

UNITED STATEs DIsTRICT COURT
SOUTHERN DIsTRIcT OF NEW YORK

(In the space above enter the full name(s) of the plaint[/(s) )

AMENDED

COMPLAINT
under the Civil Rights Act,
42 U,S C § 1983

-against-

Jury Trial:

Yes

ii

No

(check one)

(

Civ.

)

(In the space above enter the full name(s) of the defendant(s) Ifyou
cannot fit the names of all of the deJendant in the space provided,
please write “see attached” in the space above and attach an
additional sheet of paper with the full list of names The names
listed in the above caption must be identical to those contained in
Part I Addresses should not be included here)

1.

Parties in this complaint:

A

List your name, identification number, and the name and address of your current place of
confinement Do the same for any additional plaintiffs named Attach additional sheets of paper
as necessary

Plaintiff’s

Name
ID#
Current Institution
Address

B

List all defendants’ names, positions, places of employment. and the address where each defendant
ma be served Make sure that the defendant(s) listed below are identical to those contained in the
above caption Attach additional sheets of paper as necessary

Defendant No

I

Name
Where Currently Employed
Address

Rev 01/2010

Shield #

Defendant No. 2

Shield

Name

#

Where Currently Fmployed
Address

Defendant No 3

Shield

Name
Where Currently I mployed
ddress

‘4 ho did
what?

Defendant No, 4

J

Shield #

Name
V here Currently Employed
ddress

Defendant No. 5

Shield #

Name
Where Currently Employed
Address

II.

Statement of Claim:

State as briefly as possible the facts of your ease. Describe how each of the defendants named in the
caption of this complaint is involved in this action, along with the dates and locations of all relevant events.
You may wish to include further details such as the names of other persons involved in the events giving
risc to your claims. Do not cite any cases or statutes. If you intend to allege a number of related claims,
number and set forth each claim in a separate paragraph. Attach additional sheets of paper as necessary.

A.

In what institution did the events giving rise to your claim(s) occur?

B.

Where in the institution did the events giving rise to your claim(s) occur?

(

Wh

D

Facts

wh
0

Rev. 01 2010

it

date

md

approxim ste

time

did

thc

c’s ents

giving rise to

your

claim(s) occur

was

aaae
eke
Iavind?

V,he eke
sea whet
heppeeedt

ilL

Injuries:

If you sustained injuries related to the events alleged above, describe them and state what medical
treatmeat, if any. you required and received.

IV.

Exhaustion of AdmInistratlie Remedies:

e(a).
7
The Prison Litigation Reform Act (NPLRkH. 42 U S C 4 199 requires that injo action shall be
brc tight w itt spi.ct to pi iscrn c,ond kotis under scction 1983 of thi. title or any other Federal law by a
thu corr.ctiona tail ty until such admm stratis e remedies as are
ins nei r ti c.d a any jail, pri m
4dnvni,trativ rcanedsc’ are also kno* a db 5,rievanI. precedurus
availabli, an. e’ihamtcd
A.

Did your claim(s) arise while you were confined in a jail, prison, or other correctional frcility?
Yes

Rev 01 2010

No

3

If YES. name the jail, prison. or other correctional facility ‘where you ‘were confined at the time of the
ci eats gi ing rise to your claim(s).

B

Does the jail. prison oi other correctional facilit) where sour claim(b) arose haie a griennce
procedure?
Yes

C..

No

Do Not Know

Does the grievance procedure at the jail, prison or other correctional facility where your claim(s)
arose cover some or all of your claim(s)?

Yes

No

Do Not Know

If YPS, ‘which claim(s)?
D.

Did you file a grievance in the jail, prison, or other correctional facility where your claim(s) arose?
Yes

No

If NO, did you file a grievance about the events described in this complaint at any other jail,
prison, or other correctional facility?
Yes
E.

No

If you did filc a grievance, about the events described in this complaint, where did you file the
grievance?

I.

Which claim(s) in this complaint did you grieve?

2.

What was the result, if any?

What steps, if any, did you take to appeal that decision? Describe all efforts to appeal to
3.
the highest level of the grievance process.

I

If you did not file a grievance:
1.

Rn 01 2010

If there are any reasons why you did not file a grievance, state them here:

4

________________________________________--—-—----

2.

It you did not file a grievance but informed any officials of your claim, state x4ho you
informed, s hen and ho, and their response. if any.

G.

Please set forth any additional information that is relevant to the exhaustion of your administrative
remedies

Note:

You may attach as exhibits to this complaint any documents related to the exhaustion of your
administrative remedies,

V.

Relief:

State what you want the Court to do for you (including the amount of monetary compensation, if any, that
you

are

seeking

Rev 01 2010

and

the

basis

for

such

amount).

______________________________________________________________
_________________________________________________

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___________
_______
______
______________
______________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________
_____________________

‘J.
A.

Have you tiled other lawsuits in state or hderal court dealin with the same facts involved in this
action.

B.

On

Previous law suits:

If your answer to A is YES, describe each lawsuit by answering questions 1 through 7 below. (If
there is more than one lawsuit, describe the additional lawsuits on another sheet of paper, using
the same format.)

these
claims

1

.

Parties to the previous lawsuit:

Plaintiff

Defendants
2.Court (if federal court, name the district; if state court, name the county)
3.

Docket or Index number

4.

Name of Judge assigned to your case

5.

Approximate date of filing lawsuit

6.

Is the case still pending? Yes

No

If NO, give the approximate date of disposition
7.

What was the result of the case? (For example:

Was the case dismissed?

Was there

judgment in your favor? Was the case appealed?)

On
other
claims

C.

Have you filed other lawsuits in state or federal court otherwise relating to your imprisonment?
No

Yes

D.

If your answer to C is YES, describe each lawsuit by answering questions 1 through 7 below. (If
there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using
the same format.)
I.

Parties to the previous lawsuit:

Plantff

D c/cad ants

2.

Court (if federal court, name the district; if state court, name the county)

3.

Docket or Index number
N amc of Judge assigned to your case

5.
Rev. 01/2 010

Approximate date of fiing ]a\ suIt

6

__________________

6.

Is the case still pending? Yes

No

If NO, give the approximate date of disposition
What was the result of the case? (For example: Was the ease dismissed?
judgment in your faor? Was the case appealed?)

Was there

I declare under pcnalt of perjur that the foregoing is true and correct.

Signed this

day of

20_.

Signature of Plaintiff
Inmate Number
Institution Address

Note:

All plaintiffs named in the caption of the complaint must date and sign the complaint and provide
their inmate numbers and addresses.

I declare under penalty of perjury that on this

day of

.

20

,

I am delivering

this complaint to prison authorities to be mailed to the Pro Se Office of the United States District Court for
the Southern District of New York.

Signature of Plaintiff:

01 Z’oJ(i