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  • BP-9 Form Attachment

    BP-9 Form Attachment

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  • Date First Taken Into Custody*
     - -
    • Medical Care 

    • Medical Care

    • Medical Complaint Details

    • Type of Medical Issue (Check all that apply):

    • Detailed Medical Complaint Information

    • Date you first requested medical treatment for this condition:
       - -
    • How did you request treatment? (Check all that apply):
    • What response did you receive? (Check all that apply):

    • Medication and Treatment Details

    • Have you been prescribed medication for this condition?
    • Have you received all prescribed medication as directed?

    • Specialist and Outside Medical Consultation

    • Have you been referred to a specialist?
    • Date of referral:
       - -
    • Did you receive an appointment with a specialist?
    • Date of appointment:
       - -
    • Have you been seen by the specialist?
    • When were you seen by the specialist?
       - -

    • Administrative and Legal Follow-Up

    • Have you filed any previous grievances on this issue?
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    • What response did you receive? (Check all that apply):

    • Impact of Medical Neglect

    • Has the issue caused serious medical complications or worsened your condition?
    • Has the issue affected your ability to perform daily activities or work assignments?

    • Supporting Documentation

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    • Conditions of Confinement 

    • Conditions of Confinement

    • Overcrowding (18 U.S.C. § 4042(a); BOP Program Statement 1060.11)

    • Overcrowding (18 U.S.C. § 4042(a); BOP Program Statement 1060.11)(Check all that apply):
    • Have you submitted complaints about this issue?

    • Unsanitary Conditions (18 U.S.C. § 4042(a); BOP Program Statement 1600.10)

    • Unsanitary Conditions (18 U.S.C. § 4042(a); BOP Program Statement 1600.10) (Check all that apply):
    • Have you submitted complaints about this issue?

    • Food Issues (BOP Program Statement 5470.08)

    • Food Issues (BOP Program Statement 5470.08) (Check all that apply):
    • Have you submitted complaints about this issue?

    • Account Management (28 C.F.R. Part 547, Subpart C; BOP Program Statement 5470.13)

    • Account Management (28 C.F.R. Part 547, Subpart C; BOP Program Statement 5470.13) (Check all that apply):
    • Have you submitted complaints about this issue?

    • Commissary Issues (28 C.F.R. Part 547, Subpart B; BOP Program Statement 5470.12)

    • Commissary Issues (28 C.F.R. Part 547, Subpart B; BOP Program Statement 5470.12) (Check all that apply):
    • Have you submitted complaints about this issue?

    • Extreme Temperatures (18 U.S.C. § 4042; BOP Program Statement 1600.09)

    • Extreme Temperatures (18 U.S.C. § 4042; BOP Program Statement 1600.09) (Check all that apply):
    • Have you submitted complaints about this issue?

    • Supporting Documentation

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    • Disciplinary Actions 

    • Disciplinary Actions

    • False or Unfair Disciplinary Charges (28 C.F.R. § 541.5(b); BOP Program Statement 5270.09)

    • False or Unfair Disciplinary Charges (28 C.F.R. § 541.5(b); BOP Program Statement 5270.09) (Check all that apply):

    • Due Process Violations (28 C.F.R. § 541.8)

    • Due Process Violations (28 C.F.R. § 541.8) (Check all that apply):

    • Segregation/Solitary Confinement Concerns (28 C.F.R. Part 541, Subpart C; BOP Program Statement 5270.10)

    • Segregation/Solitary Confinement Concerns (28 C.F.R. Part 541, Subpart C; BOP Program Statement 5270.10) (Check all that apply):

    • Retaliatory Disciplinary Action (28 C.F.R. § 541.1)

    • Retaliatory Disciplinary Action (28 C.F.R. § 541.1) (Check all that apply):

    • Excessive or Unjust Sanctions (28 C.F.R. § 541.3; BOP Program Statement 5270.09)

    • Excessive or Unjust Sanctions (28 C.F.R. § 541.3; BOP Program Statement 5270.09) (Check all that apply):

    • Denial of Appeal Rights (28 C.F.R. Part 542; BOP Program Statement 1330.18)

    • Denial of Appeal Rights (28 C.F.R. Part 542; BOP Program Statement 1330.18) (Check all that apply):

    • Disciplinary Related Issues

    • When were you first informed of the disciplinary charge(s) or sanction(s)?
       - -
    • How were you notified of the disciplinary action? (Check all that apply):
    • What response or outcome did you receive? (Check all that apply):
    • Have you been placed in segregation/solitary/SHU confinement due to this disciplinary action?
    • Start Date
       - -
    • If placed in segregation/solitary/SHU confinement, what were the conditions like? (Check all that apply):
    • Did this disciplinary action or segregation affect your health (physical or mental)?
    • Did you seek medical or mental health attention due to this issue?
    • Date of seeking medical or mental health attention:
       - -
    • Did the medical or mental health attention you received resolve the issues caused by the disciplinary action or segregation?
    • Have other inmates also been affected by similar disciplinary actions?
    • Has the issue worsened over time?

    • Supporting Documentation

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    • Staff Misconduct 

    • Staff Misconduct

    • Abuse of Inmates (BOP Program Statement 3420.11)

    • Abuse of Inmates (BOP Program Statement 3420.11) (Check all that apply):

    • Negligence in Duty (BOP Program Statement 5500.14)

    • Negligence in Duty (BOP Program Statement 5500.14) (Check all that apply):

    • Retaliation (BOP Program Statement 3420.11)

    • Retaliation (BOP Program Statement 3420.11) (Check all that apply):

    • Staff-Inmate Communication Violations (BOP Program Statement 3420.11)

    • Staff-Inmate Communication Violations (BOP Program Statement 3420.11) (Check all that apply):

    • Harassment (BOP Program Statement 3713.24)

    • Harassment (BOP Program Statement 3713.24) (Check all that apply):

    • Unprofessional Conduct (BOP Program Statement 3420.11)

    • Unprofessional Conduct (BOP Program Statement 3420.11) (Check all that apply):

    • Discrimination (U.S. Constitution, Eighth and Fourteenth Amendments; ADA; BOP Program Statement 5500.07)

    • Discrimination (U.S. Constitution, Eighth and Fourteenth Amendments; ADA; BOP Program Statement 5500.07) (Check all that apply):

    • Staff Misconduct Incident

    • Date of Incident
       - -
    • Where there any witnesses to the Incident?
    • Did you report the Incident to prison authorities?
    • How did you report the Incident? (Check all that apply):
    • What response did you receive? (Check all that apply):
    • Has the misconduct affected your health or safety?
    • Did you seek medical or mental health attention due to this issue?
    • Date you sought medical or mental health attention:
       - -
    • Did the medical or mental health attention you received resolve the issues caused by the misconduct?
    • Have other inmates also been affected by similar misconduct?
    • Has the issue worsened over time?

    • Supporting Documentation

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    • Sentence Computation 

    • Sentence Computation

    • First Step Act (FSA) Time Credit Dispute (18 U.S.C. § 3632(d)(4); BOP Program Statement 5410.01)

    • First Step Act (FSA) Time Credit Dispute (18 U.S.C. § 3632(d)(4); BOP Program Statement 5410.01) (Check all that apply):

    • Sentence Start Date Dispute (18 U.S.C. § 3585(a); BOP Program Statement 5880.28)

    • Sentence Start Date Dispute (18 U.S.C. § 3585(a); BOP Program Statement 5880.28) (Check all that apply):

    • Jail Credit (Pre-Sentence Time Served) Dispute (18 U.S.C. § 3585(b); BOP Program Statement 5880.28)

    • Jail Credit (Pre-Sentence Time Served) Dispute (18 U.S.C. § 3585(b); BOP Program Statement 5880.28) (Check all that apply):

    • Second Chance Act (SCA) Time Credit Dispute (18 U.S.C. § 3624(c); BOP Program Statement 7310.04)

    • Second Chance Act (SCA) Time Credit Dispute (18 U.S.C. § 3624(c); BOP Program Statement 7310.04) (Check all that apply):

    • Good Time Credit Miscalculation (18 U.S.C. § 3624(b); BOP Program Statement 5880.28)

    • Good Time Credit Miscalculation (18 U.S.C. § 3624(b); BOP Program Statement 5880.28) (Check all that apply):

    • Concurrent vs. Consecutive Sentence Computation Error (18 U.S.C. § 3584; BOP Program Statement 5880.28)

    • Concurrent vs. Consecutive Sentence Computation Error (18 U.S.C. § 3584; BOP Program Statement 5880.28) (Check all that apply):

    • Sentence Computation Issues

    • Have you spoken to BOP staff about the issue?:
    • Has the issue caused hardship?

    • Supporting Documentation

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    • Inmate-on-Inmate Violence 

    • Inmate-on-Inmate Violence

    • Physical Assault (18 U.S.C. § 4042(a); BOP Program Statement 5324.12)

    • Physical Assault (18 U.S.C. § 4042(a); BOP Program Statement 5324.12) (Check all that apply):

    • Threats and Intimidation (BOP Program Statement 5270.09)

    • Threats and Intimidation (BOP Program Statement 5270.09) (Check all that apply):

    • Failure of Staff to Protect Inmate (18 U.S.C. § 4042(a); BOP Program Statement 5324.12)

    • Failure of Staff to Protect Inmate (18 U.S.C. § 4042(a); BOP Program Statement 5324.12) (Check all that apply):

    • Sexual Assault or Harassment (28 C.F.R. § 115.11; BOP Program Statement 5324.12)

    • Sexual Assault or Harassment (28 C.F.R. § 115.11; BOP Program Statement 5324.12) (Check all that apply):

    • Inmate-on-Inmate Violence Issues

    • Date of the Incident:
       - -
    • Location of the Incident:
    • Were weapons involved?
    • Did you report the incident to staff?
    • Date the Incident was reported:
       - -
    • What response or action was taken by staff? (Check all that apply):
    • Were you placed in segregation/SHU or protective custody as a result of this incident?
    • Start Date of segregation/SHU:
       - -
    • If placed in segregation/SHU or protective custody, what were the conditions like? (Check all that apply):
    • Did the incident result in physical injuries?
    • Did you receive medical attention for your injuries?
    • Date you received medical attention:
       - -
    • Did medical attention resolve the issues caused by the violence?
    • Did the incident affect your mental health?
    • Did you seek mental health attention due to this issue?
    • Date you sought mental health attention:
       - -
    • Did mental health attention resolve the issues caused by the violence?
    • Have other inmates also been affected by similar incidents of violence?
    • Has the issue worsened over time?

    • Supporting Documentation

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    • Retaliation Issues 

    • Retaliation Issues

    • Disciplinary Actions in Retaliation (28 C.F.R. § 541.5; BOP Program Statement 5270.09)

    • Disciplinary Actions in Retaliation (28 C.F.R. § 541.5; BOP Program Statement 5270.09) (Check all that apply):

    • Restrictions on Communication and Legal Rights (28 C.F.R. § 542.10; 28 C.F.R. § 540.18; 28 C.F.R. § 543.13; BOP Program Statement 1330.18; BOP Program Statement 5265.14)

    • Restrictions on Communication and Legal Rights (28 C.F.R. § 542.10; 28 C.F.R. § 540.18; 28 C.F.R. § 543.13; BOP Program Statement 1330.18; BOP Program Statement 5265.14) (Check all that apply):

    • Housing and Custody-Level Changes (18 U.S.C. § 3621(b); 28 C.F.R. § 541.22; BOP Program Statement 5100.08; BOP Program Statement 5270.10)

    • Housing and Custody-Level Changes (18 U.S.C. § 3621(b); 28 C.F.R. § 541.22; BOP Program Statement 5100.08; BOP Program Statement 5270.10) (Check all that apply):

    • Verbal or Physical Harassment by Staff (BOP Program Statement 3420.11; 28 C.F.R. § 552.20; BOP Program Statement 5521.06)

    • Verbal or Physical Harassment by Staff (BOP Program Statement 3420.11; 28 C.F.R. § 552.20; BOP Program Statement 5521.06) (Check all that apply):

    • Retaliation Affecting Living Conditions (18 U.S.C. § 4042; 28 C.F.R. § 551.1; BOP Program Statement 1600.11; BOP Program Statement 6031.04; BOP Program Statement 5360.09)

    • Retaliation Affecting Living Conditions (18 U.S.C. § 4042; 28 C.F.R. § 551.1; BOP Program Statement 1600.11; BOP Program Statement 6031.04; BOP Program Statement 5360.09) (Check all that apply):

    • Retaliation Issues

    • Date of the Retaliation Incident:
       - -
    • Has retaliation continued or escalated?
    • Did you report the retaliation?
    • Date you reported the retaliation:
       - -
    • What response or outcome did you receive?
    • Were there witnesses to the retaliation?
    • Has this retaliation affected other inmates as well?
    • Has the issue worsened over time?

    • Supporting Documentation

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    • Compassionate Release Requests 

    • Compassionate Release Requests

    • Medical Reasons (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50)

    • Medical Reasons (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50) (Check all that apply):

    • Family Circumstances (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50)

    • Family Circumstances (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50) (Check all that apply):

    • Elderly Inmate Criteria (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50)

    • Elderly Inmate Criteria (18 U.S.C. § 3582(c)(1)(A); BOP Program Statement 5050.50) (Check all that apply):

    • Compassionate Release Requests

    • Date of initial compassionate release request submission:
       - -
    • How was the request submitted? (Check all that apply):
    • Date sent to warden:
       - -
    • Response or outcome received (Check all that apply):
    • Have any changes in circumstances occurred since your initial request?
    • If medical-related, did you provide any medical documentation supporting your request?
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    • Has a medical professional supported your request?
    • Has the denial of compassionate release resulted in worsening health conditions or undue hardship?

    • Supporting Documentation

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    • Access to Programs 

    • Access to Programs

    • Substance Abuse Treatment (18 U.S.C. § 3621(e); BOP Program Statement 5330.11)

    • Substance Abuse Treatment (18 U.S.C. § 3621(e); BOP Program Statement 5330.11) (Check all that apply):

    • Educational Programs (18 U.S.C. § 3621(b); BOP Program Statement 5350.28)

    • Educational Programs (18 U.S.C. § 3621(b); BOP Program Statement 5350.28) (Check all that apply):

    • Vocational Training (18 U.S.C. § 3621(b); BOP Program Statement 5300.21)

    • Vocational Training (18 U.S.C. § 3621(b); BOP Program Statement 5300.21) (Check all that apply):

    • Recreational Programs (BOP Program Statement 5370.11)

    • Recreational Programs (BOP Program Statement 5370.11) (Check all that apply):

    • Access to Programs Issues

    • Date of first request to participate in the program:
       - -
    • How were you informed of the denial or limitation? (Check all that apply):
    • What reason was given for denial or limitation? (Check all that apply):
    • Did you file a grievance regarding this issue?
    • Date you filed a grievance:
       - -
    • Have other inmates experienced similar program denials?
    • Has this issue affected your rehabilitation, parole eligibility, or personal development?
    • Have you sought alternative solutions?

    • Supporting Documentation

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    • Work Assignments and Pay 

    • Work Assignments and Pay

    • Pay and Compensation Issues

    • Pay and Compensation Issues (Check all that apply):

    • Work Assignment Issues

    • Work Assignment Issues (Check all that apply):

    • Work Hours and Conditions

    • Work Hours and Conditions Issues (Check all that apply):

    • Work Assignments and Pay Issues

    • Date when this issue first occurred:
       - -
    • How were you notified? (Check all that apply):
    • What response or outcome did you receive? (Check all that apply):
    • Did this issue result in loss of income, privileges, or other consequences?
    • Did you attempt to resolve this issue informally?
    • Date you attempted to resolve this issue informally:
       - -
    • Have other inmates also been affected by similar work assignment or pay issues?
    • Has the issue worsened over time?

    • Supporting Documentation

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    • Access to Law Library/Legal Materials 

    • Access to Law Library/Legal Materials

    • Denial or Delay of Access

    • Denial or Delay of Access Issues (Check all that apply):

    • Inadequate Legal Resources

    • Inadequate Legal Resources Issues (Check all that apply):

    • Library Staffing and Availability

    • Library Staffing and Availability Issues (Check all that apply):

    • Access to Personal Legal Materials

    • Access to Personal Legal Materials (Check all that apply):

    • Access for Special Populations

    • Access for Special Populations Issues (Check all that apply):

    • Access to Law Library/Legal Materials Issues

    • Supporting Documentation

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    • Personal Property 

    • Personal Property

    • Lost or Stolen Property

    • Lost or Stolen Property Issues (Check all that apply):

    • Damaged Property

    • Damaged Property Issues (Check all that apply):

    • Restrictions on Personal Items

    • Restrictions on Personal Items Issues (Check all that apply):

    • Property During Transfers or Searches

    • Property During Transfers or Searches Issues (Check all that apply):

    • Compensation and Claims Process

    • Compensation and Claims Process Issues (Check all that apply):

    • Personal Property Issues

    • Supporting Documentation

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    • Mail Issues/Email Access 

    • Mail Issues/Email Access

    • Delays or Denials of Physical Mail

    • Delays or Denials of Physical Mail Issues (Check all that apply):

    • Inspection and Censorship of Physical Mail

    • Inspection and Censorship of Physical Mail Issues (Check all that apply):

    • Legal Mail-Specific Issues

    • Legal Mail-Specific Issues (Check all that apply):

    • Access and Use of TRULINCS Email

    • Email Access Issues (Check all that apply):

    • Mail Issues/Email Access Issues

    • Supporting Documentation

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    • Telephone Access 

    • Telephone Access

    • Denial or Delay of Phone Access

    • Denial or Delay of Phone Access Issues (Check all that apply):

    • Phone Costs and Charges

    • Phone Costs and Charges Issues (Check all that apply):

    • Phone System Functionality

    • Phone System Functionality Issues (Check all that apply):

    • Restrictions on Phone Use

    • Restrictions on Phone Use Issues (Check all that apply):

    • Access for Special Populations

    • Access for Special Populations Issues (Check all that apply):

    • Telephone Access Issues

    • Supporting Documentation

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    • Visiting 

    • Visiting

    • Denial or Restriction of Visits

    • Denial or Restriction of Visits Issues (Check all that apply):

    • Visiting Conditions and Environment

    • Visiting Conditions and Environment Issues (Check all that apply):

    • Visiting Hours and Scheduling

    • Visiting Hours and Scheduling Issues (Check all that apply):

    • Access for Special Populations

    • Access for Special Populations Issues (Check all that apply):

    • Visiting Issues

    • Supporting Documentation

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    • Case Management 

    • Case Management

    • Case Manager Responsiveness

    • Case Manager Responsiveness Issues (Check all that apply):

    • Access to Files

    • Access to Files Issues

    • Transfer Requests ("Closer to Home")

    • Transfer Requests Issues (Check all that apply):

    • Program Participation and Classification

    • Program Participation and Classification Issues (Check all that apply):

    • Case Management Issues

    • Supporting Documentation

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    • Disability Accommodation 

    • Disability Accommodation

    • Denial of Reasonable Accommodations

    • Denial of Reasonable Accommodations Issues (Check all that apply):

    • Inadequate Medical Care Related to Disability

    • Inadequate Medical Care Related to Disability Issues (Check all that apply):

    • Facility Accessibility Issues

    • Facility Accessibility Issues (Check all that apply):

    • Discrimination or Retaliation Based on Disability

    • Discrimination or Retaliation Based on Disability Issues (Check all that apply):

    • Communication Barriers

    • Communication Barriers Issues (Check all that apply):

    • Disability Accommodation Issues

    • Supporting Documentation

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    • Religious Practices 

    • Religious Practices

    • Denial of Religious Services

    • Denial of Religious Services Issues (Check all that apply):

    • Access to Religious Materials

    • Access to Religious Materials Issues (Check all that apply):

    • Dietary Restrictions

    • Dietary Restrictions Issues (Check all that apply):

    • Religious Group Recognition

    • Religious Group Recognition Issues (Check all that apply):

    • Religious Practices Issues

    • Supporting Documentation

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