Hall v. Department of Corrections Medical Department

—————

USDC SDNY

UNITED STATES DISTRICT COURT i DOCUMENT CALLY FILED

SOUTHERN DISTRICT OF NEW YORK ELECTRONIC.

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KEITH HALL, | py \TE FILED: _? UU □□□ 7

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Plaintiff,

-against-

DEPARTMENT OF CORRECTIONS MEDICAL Meth ONZE)

DEPARTMENT, SING SING CORR. FACILITY; ‘

CENTRAL OFFICE: FELIX EZEKWE, M.D. ESSIEN Se

PROVIDER, SING SING CORR. FACILITY; MS.

RASIA FERDOUS, MEDICAL DIRECTOR, SING

SING CORR. FACILITY; F.M.D. DANA GAGE;

CENTRAL OFFICE MEDICAL DEPARTMENT,

Defendants.

NELSON S. ROMAN, United States District Judge:

Plaintiff Keith Hall (“Plaintiff”), a pro se litigant incarcerated at Sing Sing Correctional

Facility (“Sing Sing”) and proceeding in forma pauperis, commenced this action pursuant to 42

U.S.C. § 1983 against the New York State Department of Corrections and Community Supervision

Central Office Medical Department (“Central Office Medical Department”), the Medical

Department at Sing Sing Correctional Facility (“Sing Sing Medical Department”), Dr. Felix

Ezekwe, Medical Provider at Sing Sing (“Ezekwe”), Ms. Rasia Ferdous, Medical Director at Sing

Sing (““Ferdous”), and F.M.D. Dana Gage, Central Office Medical Department (“Gage”), on July

31,2018. (See ECF No. 2.) Plaintiff alleges violations of his rights under the Eighth Amendment

to the United States Constitution arising from Defendants’ failure to provide adequate medical care

for a condition involving Plaintiffs prosthetic eye.

By Order dated November 2, 2018, the Court dismissed all claims against the Central

Office Medical Department and the Sing Sing Medical Department on Eleventh Amendment

grounds. (ECF No. 6.) Presently before the Court is the motion of Ezekwe, Ferdous, and Gage

(collectively, “Defendants”) to dismiss the remaining claims against them in their entirety pursuant

to Federal Rule of Civil Procedure 12(b)(6). (ECF No. 17.) Plaintiff does not oppose the motion.

(ECF No. 19.) For the following reasons, Defendants’ Motion is GRANTED.

BACKGROUND

I. Factual Allegations

The following facts are derived from the Complaint1 or matters of which the Court may

take judicial notice and are taken as true and constructed in the light most favorable to pro se

Plaintiff for the purposes of this motion. See Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009); Nicosia

v. Amazon.com, Inc., 834 F.3d 220, 230 (2d Cir. 2016).

Plaintiff is a prisoner in the custody of the New York State Department of Corrections and

at all relevant times was incarcerated at Sing Sing Correctional Facility. (Compl. (ECF No. 2) ¶

3.) Plaintiff states that on November 10, 2015, he told his medical provider at Sing Sing, Ezekwe,

that his prosthetic eye was not fitting correctly. (Id. ¶¶ 4, 9.) Plaintiff complained of discharge

and secretions coming from his eye. (Id. ¶ 9.) At night, while Plaintiff slept, his prosthetic eye

would fall out. (Id.) Throughout the day, Plaintiff frequently had to reposition his eye and carry

tissues to clean the discharge. (Id.) On November 25, 2015, Ezekwe referred Plaintiff to nonparty

Dr. Wandeb Charles at the Ophthalmology Department at Fishkill Correctional Facility. (Id. ¶¶

9–10.)

An appointment with Dr. Charles and nonparty Dr. John G. Bortz took place on December

3, 2015. (Id. ¶ 10.) Both doctors recommended surgery for Plaintiff’s eye socket problems, though

1 The Court notes that while Plaintiff references a number of exhibits in the Complaint, no exhibits have been filed

or otherwise brought to the Court’s attention.

it is unclear from the Complaint whether that recommendation was made at the time of the

appointment. (Id.) Though Plaintiff does not explicitly say so, it appears that he visited with Dr.

Bortz again on August 5, 2016. (Id. ¶ 12.) On that date, Dr. Bortz told Plaintiff that he had a

collapsed eye socket with chronic anophthalmic conjunctivitis and discharge due to an excessive

superior forniceal recess. (Id.) Dr. Bortz recommended that a metal plate be installed under

Plaintiff’s eye socket along the orbital floor to fill the collapsed area. (Id.) On August 7, 2016,

Dr. Bortz sent Ezekwe his recommendations. (Id. ¶ 10.) However, the Central Office Medical

Department deferred the recommended procedure. (Id.)

Plaintiff found out about the deferral on August 7, 2017, at which point he filed a grievance,

which he reports he exhausted. (Id. ¶¶ 7, 11.) Plaintiff ultimately underwent surgery with Dr.

Bortz on May 15, 2018. (Id. ¶ 13.)

LEGAL STANDARD

I. 12(b)(6)

On a 12(b)(6) motion, dismissal is proper unless the complaint “contain[s] sufficient factual

matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal,

556 U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). When

there are well-pleaded factual allegations in the complaint, “a court should assume their veracity

and then determine whether they plausibly give rise to an entitlement to relief.” Id. at 679. When

a motion to dismiss a complaint is unopposed, a court should nevertheless “assume the truth of a

pleading’s factual allegations and test only its legal sufficiency.” McCall v. Pataki, 232 F.3d 321,

322 (2d Cir. 2000).

The critical inquiry is whether the plaintiff has pled sufficient facts to nudge the claims

“across the line from conceivable to plausible.” Twombly, 550 U.S. at 555. A motion to dismiss

will be denied where the allegations “allow[] the court to draw the reasonable inference that the

defendant is liable for the misconduct alleged.” Iqbal, 556 U.S. at 678.

Pro se complaints are to be liberally construed. Estelle v. Gamble, 429 U.S. 97, 106 (1976).

They must be held to less stringent standards than complaints written by lawyers, and only

dismissed when the plaintiff can prove “no set of facts in support of his claim which would entitle

him to relief.” Estelle, 429 U.S at 106 (quoting Conley v. Gibson, 335 U.S. 41, 45–46 (1957)).

This “is particularly so when the pro se plaintiff alleges that [his] civil rights have been violated.”

Sealed Plaintiff v. Sealed Defendant, 537 F.3d 185, 191 (2d Cir. 2008). Pro se complaints must

be interpreted as raising the strongest claims they suggest, but “must still state a plausible claim

for relief.” Hogan v. Fischer, 738 F.3d 509, 515 (2d Cir. 2013).

II. 42 U.S.C. § 1983 Claims

Section 1983 provides, in relevant part, that: “[e]very person who, under color of any

statute, ordinance, regulation, custom, or usage, of any State . . . subjects, or causes to be subjected,

any citizen of the United States . . . to the deprivation of any rights, privileges, or immunities

secured by the Constitution and laws, shall be liable to the party injured.” 42 U.S.C. § 1983.

Section 1983 “is not itself a source of substantive rights, but a method for vindicating federal rights

elsewhere conferred by those parts of the United States Constitution and federal statutes that it

describes.” Baker v. McCollan, 443 U.S. 137, 144 n.3 (1979); see Cornejo v. Bell, 592 F.3d 121,

127 (2d Cir. 2010). To state a claim under § 1983, a plaintiff must allege two essential elements:

“(1) that the defendants deprived him of a right ‘secured by the Constitution or laws of the United

States’; and (2) that they did so ‘under color of state law.’” Giordano v. City of New York, 274

F.3d 740, 750 (2d Cir. 2001) (quoting Am. Mfrs. Mut. Ins. Co. v. Sullivan, 526 U.S. 40, 49–50

(1999)).

DISCUSSION

Plaintiff alleges that Defendants violated his Eighth Amendment right to be free from cruel

and unusual punishment by delaying Plaintiff’s eye socket surgery for no stated reason. Plaintiff

argues that such delay constituted deliberate indifference to his serious medical needs. Defendants

aver that Plaintiff’s claims must be dismissed because (1) Plaintiff’s allegations about a delay in

treatment do not amount to actionable medical indifference, (2) Plaintiff does not sufficiently plead

that any of the Defendants were personally involved in deferring treatment, and (3) Defendants are

entitled to qualified immunity. Defendants also state that all claims against them in their official

capacities are barred by the Eleventh Amendment. The Court addresses each argument in turn.

I. Eighth Amendment Claim

The Eighth Amendment provides: “Excessive bail shall not be required, nor excessive fines

imposed, nor cruel and unusual punishments inflicted.” U.S. Const. amend VIII. Therefore, the

Eighth Amendment “guarantees individuals the right not to be subjected to excessive sanctions.”

Miller v. Alabama, 567 U.S. 460, 469 (2012) (quoting Roper v. Simmons, 543 U.S. 551, 560

(2005). The right emanates from the basic precept of justice that punishment for crime should be

graduated and proportioned to [the] offense. Roper, 543 U.S. at 560 (citations and internal

quotations omitted). “By protecting even those convicted of heinous crimes, the Eighth

Amendment reaffirms the duty of the government to respect the dignity of all persons.” Id.

In order to assert an Eighth Amendment claim for medical indifference, a plaintiff must

plausibly allege that a defendant acted with “deliberate indifference to serious medical needs.”

Harrison v. Barkley, 219 F.3d 132, 136 (2d Cir. 2000) (quoting Estelle, 429 U.S. at 103); see also

Chance v. Armstrong, 143 F.3d 698, 702 (2d Cir. 1998). It is well-established that “the Eighth

Amendment is not a vehicle for bringing medical malpractice claims, nor a substitute for state tort

law, [and that] not every lapse in prison medical care will rise to the level of a constitutional

violation.” Smith v. Carpenter, 316 F.3d 178, 184 (2d Cir. 2003); see Estelle, 429 U.S. at 106,

(“Medical malpractice does not become a constitutional violation merely because the victim is a

prisoner.”). “Only deprivations denying the minimal civilized measure of life’s necessities are

sufficiently grave to form the basis of an Eighth Amendment violation.” Salahuddin v. Goord,

467 F.3d 279 (2d Cir. 2006) (internal quotations omitted).

Medical indifference claims under the Eighth Amendment of the U.S. Constitution and

Section 1983 require courts to engage in a two-part inquiry, one objective and the other subjective.

The objective inquiry focuses on the effect of a defendant’s conduct and the subjective inquiry

focuses on the defendant’s motive. Chance, 143 F.3d at 702. “First, the alleged deprivation must

be, in objective terms, sufficiently serious. Second, the defendant must act with a sufficiently

culpable state of mind.” Id.

In the context of medical care, two inquiries determine whether a deprivation is objectively

serious. “The first inquiry is whether the prisoner was actually deprived of adequate medical care.”

Salahuddin, 467 F.3d at 279. Because “the prison official’s duty is only to provide reasonable

care,” prison officials are liable only if they fail “‘to take reasonable measures’ in response to a

medical condition.” Id. at 279–80 (quoting Farmer v. Brennan, 511 U.S. 825, 847 (1994)). The

second inquiry is “whether the inadequacy in medical care is sufficiently serious.” Id. at 280. If

the allegedly offending conduct “is a failure to provide any treatment for an inmate’s medical

condition, courts examine whether the inmate’s medical condition is sufficiently serious.” Id. In

general, a “sufficiently serious” medical need is a “condition of urgency, one that may produce

death, degeneration, or extreme pain.” Hathaway v. Coughlin, 37 F.3d 63, 66 (2d Cir. 1994).

If the offending conduct is the “medical treatment given,” however, “the seriousness

inquiry is narrower.” Salahuddin, 467 F.3d at 280. When “the prisoner is receiving appropriate

on-going treatment for his condition,” and brings a “denial of medical care claim based on a

temporary delay or interruption in treatment,” courts look to “the severity of the temporary

deprivation alleged by the prisoner,” not “the severity of the prisoner’s underlying medical

condition.” Smith v. Carpenter, 316 F.3d 178, 186 (2d Cir. 2003); see Sledge v. Fein, No. 11-CV-

7450 (PKC), 2013 WL 1288183, at *5 (S.D.N.Y. Mar. 28, 2013) (“[I]n cases of delayed or

inadequate care, ‘it’s the particular risk of harm faced by a prisoner due to the challenged

deprivation of care, rather than the severity of the prisoner’s underlying medical condition,

considered in the abstract, that is relevant....’”) (quoting Smith, 316 F.3d at 186); see also Bellotto

v. Cnty. of Orange, 248 Fed. App’x 232, 236 (2d Cir. 2007) (“When a prisoner alleges denial of

adequate medical care, we evaluate the seriousness of the prisoner’s underlying medical condition.

When a prisoner alleges ‘a temporary delay or interruption in the provision of otherwise adequate

medical treatment,’ we focus on the seriousness of the particular risk of harm that resulted from

‘the challenged delay or interruption in treatment rather than the prisoner’s underlying medical

condition alone.’”) (quoting Smith, 316 F.3d at 185) (internal citation omitted).

A prison official acts with the requisite deliberate indifference when that official “knows

of and disregards an excessive risk to inmate health or safety…” Chance, 143 F.3d at 702 (citing

Farmer v. Brennan, 511 U.S. 825, 837 (1994)); see Farmer 511 U.S. at 837 (“[T]he official must

both be aware of facts from which the inference could be drawn that a substantial risk of serious

harm exists, and he [or she] must also draw the inference.”).

For the reasons that follow, the Court determines that Plaintiff has not adequately pleaded

either objectively serious harm or subjective intent sufficient to survive Defendants’ motion.

1. Objective Harm

Plaintiff states that he suffered discomfort arising from problems with his eye socket and a

poorly fitting prosthetic eye. Specifically, Plaintiff complains that he was “constantly adjusting

his prostetic [sic] eye and addressing chronic discharge from [his] eye, which led to constant

irritation due to discharge from eye and wiping [his] eye with toilet paper through out [sic] the

day.” (Compl. at 4.) Plaintiff further states that he “suffer[ed] with discomfort and discharge

throughout the day and live[d] with this medical condition for [nine] years.” (Id. at 5.) Finally,

Plaintiff states that his prosthetic eye would fall out while he slept and land on his pillow or the

floor. (Id. ¶ 9.)

Plaintiff does not contend that he was deprived of adequate medical treatment entirely.

Rather, he states that it was unreasonably delayed. While Plaintiff states that he suffered

discomfort due to his condition for nine years, he was not recommended surgery until December

3, 2015, at the earliest, and he does not complain that his medical treatment prior to the

recommendation was inadequate. (Id. ¶ 10.) One year and approximately nine months passed

between the time that Dr. Bortz’s diagnosis and treatment recommendation was passed on to

Defendant Ezekwe on August 7, 2016, and Plaintiff’s surgery on May 16, 2018. Plaintiff’s

position is that this delay was objectively severe for purposes of an Eighth Amendment deliberate

indifference analysis.

“Although a delay in providing necessary medical care may in some cases constitute

deliberate indifference, [the Second Circuit] has reserved such a classification for cases in which,

for example, officials deliberately delayed care as a form of punishment; ignored a ‘life-

threatening and fast-degenerating’ condition for three days; or delayed major surgery for over two

years.” Demata v. N.Y. State Corr. Dep’t of Health Servs., 198 F.3d 233 (2d Cir. 1999)

(unpublished) (citations omitted); see Ferguson v. Cai, No. 11-CV-6181, 2012 WL 2865474, at

*4 (S.D.N.Y. July 12, 2012) (“Where temporary delays or interruptions in the provision of medical

treatment have been found to satisfy the objective seriousness requirement in [the Second] Circuit,

they have involved either a needlessly prolonged period of delay, or a delay which caused extreme

pain or exacerbated a serious illness.”); c.f. Lloyd v. Lee, 570 F. Supp. 2d 556, 568 (S.D.N.Y. 2008)

(finding “a sixteen-month delay from the time [the plaintiff] was injured until he finally obtained

relief in the form of surgery on his shoulder,” to be sufficient to defeat a motion to dismiss where

the plaintiff “purportedly experienced extreme pain, discomfort, and loss of mobility” throughout

the relevant period); Espinal v. Coughlin, 98 Civ. 2579(RPP), 2002 WL 10450, at *3 (S.D.N.Y.

Jan. 3, 2002) (no deliberate indifference of treatment for ruptured ACL, a common knee injury,

where surgery was delayed for three years) (quotation omitted).

Here, Plaintiff makes no allegations that his condition was life-threatening and fast-

degenerating, that it worsened because of the delay, or that the delay was punitive. Indeed, Plaintiff

does not state that he suffered any pain, that his daily activities were seriously affected, or that his

condition was deteriorating. Rather, Plaintiff suggests that his primary complaint was

“discomfort” and the inconvenience of having to re-insert his prosthetic eye in the morning and

dab away discharge during the day. Moreover, through Plaintiff’s entire waiting period, he alleges

that he filed a single grievance and apparently did not seek further treatment from his medical

provider, suggesting that Plaintiff suffered little as a consequence of the delay.

In light of the foregoing, the Court concludes that the Complaint, as pleaded, does not

plausibly assert that the alleged delay in Plaintiff’s surgical treatment was serious enough to violate

Plaintiff’s constitutional rights.

2. Subjective Intent

Even if Plaintiff had adequately pleaded an objectively serious harm, he does not state an

Eighth Amendment claim because he fails to present any facts tending to support an inference of

deliberate indifference on the part of Defendants. Plaintiff does not contend that he complained

to any of the Defendants about any adverse medical effects from the delay or that Defendants

ignored his complaints. Indeed, the only Defendant Plaintiff specifically alleges even knew about

his underlying medical complaints is Ezekwe. Plaintiff states that Ezekwe referred him to an

ophthalmologist within a month of his examination of Plaintiff, that Dr. Bortz sent his

recommendations to Ezekwe, and that Ezekwe later advised Plaintiff that his surgery had been

deferred. (Compl. ¶¶ 9–11.) These actions, standing alone, do not evince a disregard of a

substantial risk to Plaintiff’s health or safety. See Farmer, 511 U.S. at 837 (requiring official to

“know of and disregard[] an excessive risk to inmate health”); James v. Correct Care Sols., No.

13-CV-0019(NSR), 2013 WL 5730176, at *6–7 (S.D.N.Y. Oct, 21, 2013) (noting that deliberate

indifference requires more than allegations about a delay in treatment); Bell v. Jendell, 980 F.

Supp. 2d 555, 562 (S.D.N.Y. 2013) (dismissal proper in absence of allegations that “the delay was

either intentional or reckless”).

Plaintiff has failed to establish either prong of a deliberate indifference claim under the

Eighth Amendment. Accordingly, Plaintiff’s Eighth Amendment claim against Defendants is

dismissed without prejudice. To the extent that Plaintiff can provide factual allegations curing the

foregoing deficiencies, Plaintiff is granted leave to replead his claim. Because Plaintiff’s amended

complaint will completely replace, not supplement, the original complaint, any facts or claims that

Plaintiff wishes to remain must be included in the amended complaint.

II. Personal Involvement

Defendants argue that Plaintiff’s Eighth Amendment claim fails for the additional reason

that Plaintiff did not allege personal involvement on the part of any Defendant in the decision to

defer his surgery. The Court agrees.

In general, “personal involvement of defendants in alleged constitutional deprivations is a

prerequisite to an award of damages under § 1983.” McKinnon v. Patterson, 568 F.2d 930, 934

(2d Cir. 1977). “[A] defendant in a § 1983 action may not be held liable for damages for

constitutional violations merely because he [or she] held a high position of authority.” Black v.

Coughlin, 76 F.3d 72, 74 (2d Cir. 1996); see also Grullon v. City of New Haven, 720 F.3d 133,

138–39 (2d Cir. 2013). Personal involvement of a supervisory defendant may be shown by

evidence of any of the following factors (the “Colon factors”):

(1) the defendant participated directly in the alleged constitutional violation, (2) the

defendant, after being informed of the violation through a report or appeal, failed

to remedy the wrong, (3) the defendant created a policy or custom under which

unconstitutional practices occurred, or allowed the continuance of such a policy or

custom, (4) the defendant was grossly negligent in supervising subordinates who

committed the wrongful acts, or (5) the defendant exhibited deliberate indifference

to the rights of inmates by failing to act on information indicating that

unconstitutional acts were occurring.

Grullon, 720 F.3d at 139 (quoting Colon v. Coughlin, 58 F.3d 865, 873 (2d Cir. 1995)).

Notably, “mere ‘knowledge and acquiescence’” to unconstitutional conduct, or mere

failure to act on a complaint, without more, fails to state a claim under Section 1983. Faulk v.

N.Y.C. Dep’t of Cor., No. 08-CV-1668(LGS), 2014 WL 239708, at *10 (S.D.N.Y. Jan. 21, 2014);

Mateo v. Fischer, 682 F. Supp. 2d 423, 430 (S.D.N.Y. 2010) (“ [T]he receipt of letters or

grievances, by itself, does not amount to personal involvement.”).

Here, Plaintiff repeatedly claims that “Medical Central Office” was responsible for the

determination to defer Plaintiff’s surgical procedure. (Compl. ¶¶ 10–11.) As previously discussed,

Plaintiff does not describe any actions at all taken by Defendants Ferdous and Gage, and only

states that Defendant Ezekwe referred him to an ophthalmologist and passed on information about

the surgery deferral to Plaintiff. These facts are far from sufficient to support Defendants’ personal

involvement in a constitutional deprivation. Even if Plaintiff had adequately pleaded a

constitutional violation, the Complaint would have to be dismissed on this additional ground.

Should Plaintiff elect to file an amended complaint, this deficiency must be cured.

III. Qualified Immunity Defense

Defendants argue in the alternative that Plaintiff’s Eighth Amendment claim must be

dismissed based on the defense of qualified immunity. Because the Court has dismissed the Eighth

Amendment claim as insufficiently pleaded on the grounds described above, it declines to address

Defendants’ qualified immunity defense at this juncture.

IV. Official Capacity Claims

Lastly, Defendants argue that any official capacity claims against Defendants must be

dismissed as barred by the Eleventh Amendment. To the extent Plaintiff has alleged any official

capacity claim against any of Defendants, it is well-settled that the Eleventh Amendment bars

claims for monetary damages against state officials acting in their official capacities. “[T]he

Second Circuit has held that ‘ [t]o the extent that a state official is sued for damages in [her] official

capacity, such a suit is deemed to be a suit against the state, and the official is entitled to invoke

the Eleventh Amendment immunity belonging to the state.’” Davis v. Westchester Cty. Family

Court, No, 16-CV-9487 (KMK), 2017 WL 4311039, at *6 (S.D.N_Y. Sept. 26, 2017) (quoting Gan

v. City of New York, 996 F.2d 522, 529 (2d Cir. 1993)). The Eleventh Amendment generally

“forbids suits against states for monetary damages.” Kirkendall v. Univ. of Connecticut Health

Ctr., 205 F.3d 1323 (2d Cir. 2000). Thus, Plaintiffs claims for monetary damages against

Defendants in their official capacities are dismissed with prejudice.

CONCLUSION

For the foregoing reasons, Defendants’ motion to dismiss is GRANTED. Plaintiff ’s claims

against Defendants in their official capacities are dismissed with prejudice. Plaintiff's claims

against Defendants in their individual capacities are dismissed without prejudice and with leave to

replead. Plaintiff may file an Amended Complaint consistent with this Opinion on or before

August 28, 2020. An Amended Civil Rights Complaint form is attached to this Order. Defendants

are then directed to answer or otherwise respond by October 2, 2020. Failure to file an Amended

Complaint within the time allowed, and without good cause to excuse such failure, will result in

dismissal of Plaintiff's Complaint with prejudice.

The Clerk of the Court is respectfully directed to terminate Defendants’ Motion to Dismiss

at ECF No. 17. The Clerk of the Court is further directed to mail a copy of this Opinion to Plaintiff

at his last address listed on ECF and show proof of service on the docket.

Dated: July 21, 2020 SO See

White Plains, New York vo ALA a —_——

. United States District Judge

13 .*

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF NEW YORK

CVE

Write the full name of each plaintiff. (Include case number if one has been

assigned)

“against- COMPLAINT

(Prisoner)

Do you want a jury trial?

ssssssss...0.0.0. L1Yes LINo

Write the full name of each defendant. If you cannot fit the

names of all of the defendants 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 above must be identical to those contained in

Section IV.

NOTICE

The public can access electronic court files. For privacy and security reasons, papers filed

with the court should therefore not contain: an individual’s full social security number or full

birth date; the full name of a person known to be a minor; or a complete financial account

number. A filing may include only: the last four digits of a social security number; the year of

an individual’s birth; a minor’s initials; and the last four digits of a financial account number.

See Federal Rule of Civil Procedure 5.2.

Rev. 5/20/16

I. LEGAL BASIS FOR CLAIM

State below the federal legal basis for your claim, if known. This form is designed primarily for

prisoners challenging the constitutionality of their conditions of confinement; those claims are

often brought under 42 U.S.C. § 1983 (against state, county, or municipal defendants) or ina

“Bivens” action (against federal defendants).

L] Violation of my federal constitutional rights

L] Other:

II. PLAINTIFF INFORMATION

Each plaintiff must provide the following information. Attach additional pages if necessary.

First Name Middle Initial Last Name

State any other names (or different forms of your name) you have ever used, including any name

you have used in previously filing a lawsuit.

Prisoner ID # (if you have previously been in another agency’s custody, please specify each agency

and the ID number (such as your DIN or NYSID) under which you were held)

Current Place of Detention

Institutional Address

County, City State Zip Code

II. PRISONER STATUS

Indicate below whether you are a prisoner or other confined person:

L] Pretrial detainee

L] Civilly committed detainee

Immigration detainee

L] Convicted and sentenced prisoner

L] Other:

IV. DEFENDANT INFORMATION

To the best of your ability, provide the following information for each defendant. If the correct

information is not provided, it could delay or prevent service of the complaint on the defendant.

Make sure that the defendants listed below are identical to those listed in the caption. Attach

additional pages as necessary.

Defendant 1:

First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work Address

County, City State Zip Code

Defendant 2:

First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work Address

County, City State Zip Code

Defendant 3:

First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work Address

County, City State Zip Code

Defendant 4:

First Name Last Name Shield #

Current Job Title (or other identifying information)

Current Work Address

County, City State Zip Code

STATEMENT OF CLAIM

Place(s) of occurrence:

Date(s) of occurrence:

FACTS:

State here briefly the FACTS that support your case. Describe what happened, how you were

harmed, and how each defendant was personally involved in the alleged wrongful actions. Attach

additional pages as necessary.

INJURIES:

If you were injured as a result of these actions, describe your injuries and what medical treatment,

if any, you required and received.

VI. RELIEF

State briefly what money damages or other relief you want the court to order.

VII. PLAINTIFF’S CERTIFICATION AND WARNINGS

By signing below, I certify to the best of my knowledge, information, and belief that: (1) the

complaint is not being presented for an improper purpose (such as to harass, cause unnecessary

delay, or needlessly increase the cost of litigation); (2) the claims are supported by existing law

or by anonfrivolous argument to change existing law; (3) the factual contentions have

evidentiary support or, if specifically so identified, will likely have evidentiary support after a

reasonable opportunity for further investigation or discovery; and (4) the complaint otherwise

complies with the requirements of Federal Rule of Civil Procedure 11.

I understand that if I file three or more cases while I am a prisoner that are dismissed as

frivolous, malicious, or for failure to state a claim, I may be denied in forma pauperis status in

future cases.

I also understand that prisoners must exhaust administrative procedures before filing an action

in federal court about prison conditions, 42 U.S.C. § 1997e(a), and that my case may be

dismissed if I have not exhausted administrative remedies as required.

I agree to provide the Clerk's Office with any changes to my address. I understand that my

failure to keep a current address on file with the Clerk's Office may result in the dismissal of my

case.

Each Plaintiff must sign and date the complaint. Attach additional pages if necessary. If seeking to

proceed without prepayment of fees, each plaintiff must also submit an IFP application.

Dated Plaintiff's Signature

First Name Middle Initial Last Name

Prison Address

Date on which | am delivering this complaint to prison authorities for mailing: