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WYOMING WDOC Form 321 DEPARTMENT OF CORRECTIONS Inmate Grievance Form Page 1 of 2 Last Revised 02/12/07 INMATE GRIEVANCE FORM Check here if this is an EMERGENCY Grievance Inmate Name Institution Date WDOC Unit/Cell Time When completing this form you may provide up to two 2 additional pages if necessary. Summary of the incident or occurrence giving rise to the grievance or reason for the grievance Summarize your attempts to informally resolve the issue e.g. verbal discussions submission of Inmate Communication Form etc. I request the following grievance resolution or remedy Inmate Signature Administrative Use Grievance Number WYOMING DEPARTMENT OF CORRECTIONS 1934 Wyott Drive Suite 100 Cheyenne Wyoming 82002 TELEPHONE 307 777-7208 FAX 307 777-7846 WEBSITE http //corrections. wy. gov INSTRUCTIONS FOR INMATE GRIEVANCE FORM After attempting to resolve a problem by first speaking with appropriate staff and second by use of WDOC Form WDOC Form 320 Inmate Communication Form an inmate may file Grievances will not be accepted or processed if they are not on the approved WDOC Form 321 or if they exceed the space authorized by the form. A completed copy of WDOC Form 321 should be submitted to the grievance manager within thirty 30 calendar days of the incident or occurrence giving rise to the issue/dispute. Summary of the incident or occurrence giving rise to the grievance or reason for the grievance Summarize your attempts to informally resolve the issue e.g. verbal discussions submission of Inmate Communication Form etc. I request the following grievance resolution or remedy Inmate Signature Administrative Use Grievance Number WYOMING DEPARTMENT OF CORRECTIONS 1934 Wyott Drive Suite 100 Cheyenne Wyoming 82002 TELEPHONE 307 777-7208 FAX 307 777-7846 WEBSITE http //corrections. wy. gov INSTRUCTIONS FOR INMATE GRIEVANCE FORM After attempting to resolve a problem by first speaking with appropriate staff and second by use of WDOC Form WDOC Form 320 Inmate Communication Form an inmate may file Grievances will not be accepted or processed if they are not on the approved WDOC Form 321 or if they exceed the space authorized by the form. A completed copy of WDOC Form 321 should be submitted to the grievance manager within thirty 30 calendar days of the incident or occurrence giving rise to the issue/dispute. Grievances must be written in a civil and respectful tone and manner. An inmate grievance must include A complete description of the incident action or application of the policy being grieved. A simple and straightforward summary of the incident or occurrence giving rise to the grievance or reason for the grievance and a requested grievance resolution or remedy. The date and approximate time of occurrence and the date and time of the grievance filing A brief summary of the attempts made to informally resolve the issue. Repetitive grievances on an issue which has already been addressed will not be accepted or processed. An inmate may not submit a group grievance that represents other inmates or act as a spokesperson for other inmate s. Completed Inmate Grievances and additional attachments should be placed into the secure designated receptacle in the correctional facility for pickup and processing by the grievance manager and/or his/her support staff. Or the forms may be given to the unit supervisor for delivery. Furthermore if the inmate has any referenced documents such as inmate communications WDOC Form 320 etc. it is recommended that copies of those documents also be attached to the grievance for reference grievance form. Only one 1 grievance per incident per inmate will be allowed and once an issue is grieved the issue may not be raised in future grievances at the same step in the grievance process unless there is a new incident and new information is available about the issue. Forms may also be placed into the outgoing mail addressed to the grievance manager. A written decision shall be forwarded to the grievant within ten 10 working days after receipt of WDOC Form 321 unless an extension has been granted to by the grievant or unless the grievant has been notified in writing of an extension of time for a response.