!(b)(6); (b)(7)(C) From: Sent: 22 Aug 2018 17:37:44 +0000 To: J I (b)(6); (b)(7)(C) Cc: Subject: FW: Follow-up after HERNANDEZ call Attachments: streamlined transfer process Bed Space Request for Transfer to Cibola from SYS/POE (20 subjects), RE: streamlined transfer process Bed Space Request for Transfer to Cibola from SYS/POE (20 subjects), RE: streamlined transfer process Bed Space Request for Transfer to Cibola from SYS/POE (19 subjects), Updated movement summary for Monday and Tuesday, 1-216&203 12TG SYS­ AEU to SLRDC on 05-14-2018.xls, IAO-handbook.pdf FYI I j(b)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 732 (b)(6); Cell: (202) 270- �}(?)( !/b)/6): /b\/7\/C\ From: kb)(6); (b)(7)(C) Sent: Wednesday, August 22, 2018 12:00 PM To: !(b)(6); (b)(7)(C) Subject: Follow-up after HERNANDEZ call !(b)/6): (b)(7)(C) ! I have attached emails as you requested. The attachments may not be in order. I have attached the initial bedspace request made byl1h11R1· 1h1m1r1 b11 05/12 @ 1530. in Cibola. I have attached the approval email from l(b)(6); �I have attached the approval email from ICE Air Operations for 05/15 flight. I have attached my email requesting San Luis transport team to pick up and transfer Hernandez to San Luis and then to the flight line to El Paso. I If you need clarification on any of the emails, please let me know. I also have included ICE Air Operations handbook. Page 19 has guideline regarding the TB. Detainees who do not present with symptoms consistent with TB and have not been tested for TB are eligible for air transport, subsequent to a TB symptom screening by the Flight Nurse (TB testing should be accomplished as soon as feasible at the receiving facility). 2020-ICLl-00006 579 Thank you, !(b\f6\: (b)b7\(C) J SDDO AOIC - Otay Mesa Detention Center - San Diego Field Office Cell: 415-716- (b)(6); (b)(?)( Desk: 619-661 2020-ICLl-00006 580 kb)(6); (b)(?)(C) From: 12 May 2018 22:30:26 +0000 #ELP-EPC-DETENTION-SDDO;#ELP-ABQ-COORD-NOTIFY Sent: To: (b)(6); (b)(?)(C) l Subject: SYS/POE (20 subjects) streamlined transfer process Bed Space Request for Transfer to Cibola from Good Afternoon, ICE/ERO San Diego is requesting the transfer of the subjects listed below to the Cibola County Correctional Center (CCCC) under the streamlined transfer process. The subjects were apprehended at the San Ysidro Port of Entry and do not have any community, family or attorney ties within the San Diego AOR. Additionally, I have included in the list the 3 subject that were accepted at CCCC but didn't make the flight last week. EARM has been updated and I'll ask OFO to annotate the 1-213 as well. Thank you, l\�1\�1;�, I 213-220�\�1\�1;, 1 b)(6); (b)(?)(C) Hernandez, Jeffry 206 418 141 (b)(6); (b)(?)(C) 2020-ICLl-00006 581 (b)(6); (b)(7)(C) l (b)(6); (b)(7)(C) _____________ .__ I ( approved but did not make flight) ___, approved but did not make flight) 6)'""" 7)'-'(C..:..) __________,l(approved but did not make flight) .,_(l b""")(.... ; (b....)(""' 2020-ICLl-00006 582 From: !(b)(6); (b)(7)(C) Sent: ! 13 May 2018 02:20:40 +0000 �ELP-EPC-DETENTION-SDDO;#ELP-ABQ-COORD- l(b)(6); (b)(7)(C) To: NOTIFY j ' 0 j Subject: RE: streamlined transfer process Bed Space Request for Transfer to Cibola from SYS/POE (20 subjects) Abq-Cibola approves bed space. Coordinate with El Paso and IAO for transfer. l(b)(6); (b)(7)(C) SDDO ICE Alb 505-235- I ue From:l(b)(6); (b)(7)(C) Date: Saturday, May 12, 2018, 16:30 -P', #ELP-ABQ- To: #ELP-EPC-DETE TION-SDDO <-!rer, DE Sub Off�e DVN - ERO - Dotiovan, CA !RP Sub Off',ce DVS • ERO • CDf Denver, CO Sub-Office EAZ • ELOY, AZ., SERVICE PROCESSING CENTER (DOCKET CONTROL OFFICE) ECC- EL CENTRO, CA, DOCKET CONTROL OFFICE EDC •ERO • Eden. 1X IHP SUb-Office ELP • EL PASO, 1X, DOCKET CONTROL OFFICE EPC ·ERO· El Paso, 1XSPC Sub-Off�e ESM - ERO - Elizabeth, NJ Detention Center.Sub Office ETW •ERO - Etowah, AL Sub Office En<· DALLAS EAST, MCAT EUG • ERO·Eugene, OR Sub Office FAY· ERO·Fayetteville, AA Sub Office FLO - FLORENCE, AZ, SERVICE PROCESSING CENTER (DOCKET CONTROL OFFICE) FMY •ERO•Fort Myers, FL Sub Office FOS·ERO·FUGITIVE OPERATIONS SUPPOOT CENTER FRO - ERO - Frederick, CO, Sub offi09 FRE •ERO•Fresno, CA Sub Office FSA - ERO - Fort Smith, AR Sub Office GJC·ERO· Grand Junctioo. CO Sul>-Offce GNS • ERO- GaJlesvi-lle, GA Sub Office GPR- ICE ERO GUAYNABO Detention Facility GRF - ERO • Grand Forks, NO Sub Office GRI • ERO • Grand Island, NE Sub Off�• GRN• ERO· Greensboro, NC Sub Office GRR- ERO- Gr00t, SC Sub-Off',ce GSC • ERO - GSenwood Springs, CO Sub-Office GUL·ERO • Gulfport, LA Sub Office HAR· HARTFORD, CT, DOCKET CONTROL OFFICE HBG. ERO. Hamsonb..-g, VA Sub Office HOF • ERO • Houston, 1X CDF Sub-Office HEL·ERO· HELENA.MT Sub Office HEN- ERO - Hende<'S(lrl. NC Sub Office HFE • ERO HISTORICAL FINGERPRJNT ENROLLMENT PROJECT HHW • HONOLULU, HI, DOCKET CONTROL OFFICE Status 1A 1B 1C 2A 28 3 5A 8A 88 8C 1O 11 12 13 14 15 16 SB 5C 50 5E 5F 80 8E 8F 8G 8H 81 9 Criminal_History Abduct-No Ransom or Assault Abomfacient Abortion Abortional Act Submission 10 AbortionaJ Act on other Abortional Act on Sett Abscond While On Parole Abscond While On Probalion Agg. Assault - Police Off.cer-Gun Agg. Assault - Poltee Offtcer-S1ron9a,m Agg. Assault - Police Officer-Weapon Agg. Assault - Public Officer-Gun Agg. Assault - Publ!c Offlcer-Sll'Or)Qal'm Agg . Assault- Public Officer-Weapon Aggravated Assault Aiding Prisoner Escape Air'C:raft. The-ft Altering ldentfflcatlon On Weapon Ampt,elamlrte Amphetamine - Manufacturr'lg Amphetamine• Possession Amphetamine - Seit Anarchism Antitrust Arsoo Assault Assembly • Unlawful Bail• Personal Recognizance Bail- Secured Bond Barblturat0 Barbiturate - Manufacturing Barbiturate - Possession Barbiturate • Set Battery Bestiality Bigamy Body Armor (poss.fuse in furth. crime) Bool(making Bribe Bribe - Giving B ribe - Offering Bribe •Receiving Bribery Burglary Burglary • Banking-type Inst. Burning Card Game Card Game- Operating Carjacking-Armed Carrying Concealed Weapon Carrylng ProhlbltOO Weapon Civi Rights Cocaine Cocaine • Possession Cocaine • Sell Cocaine - Smuggle Commercial Sex Compounding Crime Computer Crimes Conceal Stolen Property Coodltlonal Release Violation Conftict Of Interest Conservation Conservation- Animals Conse-Nafxln - Birds ConseNation • Environment Conser...ation - Flsh ConseNadon- License-Stamp Conspiracy Contompt Of Congress Contempt Of Cour1 Contempt Of LegjslattJ,0 Conlri:luting to Oelinq. of Minor Cosmetics - Adulterated Cosmetics- Heatth or Safely Cosmetics - Misbranded Counterfeillng Counterfeic.ing Other Crimes Against Person Crosslflg Poltee lines Crvetty Towaro Child Cruelty Toward Dlsablod Cruelty Toward Elderly Cruelty Toward Wrfe Damage Property Damage Property- Business Damage Property - Business w/Exploslve Damage Property - Private Damage Property • Private w/Exp1os1ve Damage Property• Public DarT1.19e Property • Public w/Ex,plost.'e Dangerous Drugs Deceptive Business Practices Desecrating Flag Dice Game Dice Game - Operating Disorderty Conduct Orvulge Eavesdrop lnbmallon DM.Jlge Eavesdrop Otdor Oiwlge Message Conlents 2020-ICLl-00006 597 Clas,5_Level Gang_Membership y A N B C D IRAN IRAQ IRELA !$RAE fTALY COTED JM1Al JAPAN JORDA KAZAK KENYA KIRIB KOREA KOSOV KUWAI KYRGY LAOS LATVI LEBAN LESOT UBER LIBYA LIECH LllHU LUXEM MACAU MACED MAOAG MALAW MALAY MALDI MALI MALTA NMARI MARSH MARTI MAUTA MAUTI MEXJC FSM MOLDO MONAC MONGO MONTE MONTS MOROC MOZAM NAMIB NAURU NEPAL NETHE ANTIL NEWCA NEWZE NICAR NIGE N IGIA NIUE NQUOT NKORE NORWA OMAN PAKIS PALAU PANAM PAPUA PARAG PERU PHILI PITCA POLAN PORTU PIJERT QATAR REUNI ROMAN RUSSI RWANO SAMOA $ANMA SAOTO SAUDI SENEG SRBIA SEYCH SIERR SINGA SLOVA SlOVE SOLOM SOMAL SAFRI SKORE SOSUD SPAIN SRILA STHEL STKIT STLUC STPIE STVlN HLG - HARLINGEN, TX. DOCKET CONTROL OFFICE Hr..rT - ERO- Hunts�, lXIRP Sub-Office HOU• HOUSTON, TX, DOCKET CONTROL OFFICE HPC • ERO • Houston, TX $PC Sut>-Offioe HVR ·ERO·HAVRE.MT Sub Office IFI - ERO·ktaho Falls, k:!aho Sub Office IMP - ERO - Imperial, CA Sob Office INP • ERO - Indianapolis, IN Sub-Office JAC - ERO - Jacksonville, Fl Sub Office JAK - ERO · Jackson. MS Sub Off1ee JNA - ERO - Jena, LA Sub Office KAN • KANSAS, MO. DOCKET CONTROL OFFICE KCD - ERO - Karnes City, TX Sub-Office KNX - ERO - Knoxville, TN Sub Office KRO• KROME, MIAMI, FL, DOCKET CONTROi. OFFICE LAF • ERO • Lafayette, LA Sub-Office LAK ·ERO· Lake Charies. LA Sub Office LAS - ICE ERO LAS CRUCES Sub Office LBK • ERO· LUBBOCK, TX SUB-OFFICE LCY - ERO- Orange, CA Sub Offioe LIV - ERO - LMngstoo, TX Sub-Office LNB• ICE ERO LONG BEACH Sub Office LOM • ERO - Lompoc, CA IHP Sub-Office LOS· LOS ANGELES, CA, DOCKET CONTROL OFFICE i LOU - ERO - Lou sville. KY Sub-Office LRA • ERO· Little Rock, AR Sub-Office LRO - ERO- Laredo, TX Detention Center LSC - Law Enforcement Support Cente, - ERO LTV · ICE ERO-Lorton, VA Sub-Office LVG - LAS VEGAS, NV, DOCKET CONTROL OFFICE MAN • ERO• Manchester. NH Sul>-Office MDC - ICE ERO WOODSTOCK Detention Facility MEO • ERO - M9dford, OR Sub Offico MEM • ERO • Memphis, TN Sub Office MES • ICE ERO MESA Sub Office MGA• ERO• Mootgome,y, AL Sub Office MIA • MIAMI, fl, DOCKET CONTROL OFFICE MIO • ICE ERO-Midland, TX Sub-Offico MIL • ERO - Milwauk.ee, W1 Sut>-Off'tce MLN - ERO - Marlton, NJ Sub Office MLU • ERO • MOUNT LAUREL NJ Sub Office MOA - ERO - Moi>le, AL Sub Offioe MSK • ERO• !Nine, CA Sub Office MTG - ERO - Montgomery COUllty, TX Sub Office NEW - NEWARK, NJ, DOCKET CONTROL OFFICE NLI • LONG ISLAND, NY SUB-OFFICE NOL • NEW ORLEANS, LA, DOCKET CONTROL OFFICE NOR• ERO• NORFOLK.VA Sub Office NPR - ERO - North Platte, NE Sub Office NSV • ERO - Nashville, TN Sub Office NYC · NEW YORK, NY, DOCKET CONTROL OFFICE OAK - OAKCALE PROCESSING CENTER FEDERAL ALIEN DETENTION FACIUTY OGU• ERO• Ogden, UT Sub Office OKC. ERO. Oklahoma City, OK Sub-Offic• OMA • OMAHA, NE, DOCKET CONTROL OFFICE OOP - ERO - Otero County Processing Center ORI. • ORLANDO, FL. DOCKET CONTROL OFFICE OTM - ERO· Otay CCA facility, CA Sub Office PCS • ERO - Pe,cos. TX IHP Sub-Office PHI· PHILADELPHIA. PA, DOCKET CONTROL OFFICE PHO· PHOENIX, AZ. DOCKET CONTROL OFFICE PIC• PORT ISABEL. TX, DOCKET CONTROL OFFICE PIT·PITTSBURGH, PA, DOCKET CONTROL OFFICE PKE • ERO - Pike County·. PA Sub Office POM • PORTLAND, ME, DOCKET CONTROL OFFICE POO • PORTLAND, OR, DOCKET CONTROL OFFICE PRL • Prairieland Detentton Center PRO- PROVIDENCE, RI, DOCKET CONTROL OFFICE PRU • ERO • Provo. UT Sub Office PUE • ERO • Pueblo, CO Sub-Office RCM - ERO - Rlchmond, VA Sub Office RDU • ERO • Raleigh/Durham. NC Sub-Office RED • Redding, CA Sub-Office REN·RENO, NV, DOCKET CONTROL OFFICE RIC ·ERO·Richland, WA Sub 0/f,ce RII• ERO• Roel< lslafld, IL Sub-Office RIK • ERO·RIKERS ISLAND, NY SUB-OFFICE RMK ·ERO·Roanoke, VA Sub 0/f,ce RPC • ERO • Rapid City, SO Sub Office RSW - Roswell, NM Sub-Office SAA • ERO - Santa Ana, CA Sub-Office SAC - ERO - Sacramento, CA Sub Offioe SAi - ERO - Salpan, MP Sub Offic:B SAJ • SAN JUAN, PR, SERVICE PROCESSING CENTER (DOCKET CONTROL OFFICE) SAV ·ERO·Sa=ah, GA Sub-Office S8D • ERO • San Bernardino, CA Sub Office SEA·SEATTLE, WA, DOCKET CONTROL OFFICE SFO - ERO • SIOUX FALLS,SO Sub Office SFR • SAN FRANCISCO, CA, DOCKET CONTROL OFFICE SGU. ERO. St. Georgo, UT Sub Office SLC • SALT LAKE CITY, UT, DOCKET CONTROL OFFICE $MM · ERO - Sa.ult Sle. Marie, Ml Sub--Office SNA • ERO • San Antonio, TX Field Office SND • SAN DIEGO, CA, DOCKET CONTROL OFFICE SNG • SAN ANGELO SUB OFC TX OCO $NJ· ERO· SAN JOSE,CA Sub Office SNS • ERO • Shelby, MT Sub Offloe SPG • ERO· Springfield. MO Sub-Off�e SPM - ST. PAUL, MN, DOCKET CONTROL OFFICE SPO ·ERO· SPOKANE.WA Sub Office SPR·ERO·Springfield, MA Sub Office Domestic VK>lence Drtvn'lg Under lnfklence Drugs Drivtog Under Influence Ujuor Drug F'>ossession Drug Trafflcking Dn,gs·Adutteropeny Embezz� - Interstate Shipment Embezzte - Postal Embezzle • Public Property Entioe Mjnor for lndeoent Purp. Entice Mlnot for Prostitution Escape Escape From Custody Espionage Establish Gambling P1aoe Evidence • Destroying Exploitation of a Minor Exploitation/Enticement Explosives • Possession Exptosiv&s - Teaching Use Explosives • Transporting Explosives - Using Extortion Extortion- Threat Injure Person Faitlng to M::i-...e On Faiklre Rel'.X)rt Crime Faiture To Appear Fai-.ire To Register Sex orrendef False Cttizenship False lmprisoo.-Mino<�parental False lmprlson.-Minor-Parental False lmprlsonmenl Family Offense Fede�aterlal Witness Fifing Weapon Right - Escape Flight To Avoid Food - Adulterated Food - Health or Safety Focxt• Misbranded Forcible Purse Sl\cltehing Forgery Forgery Of Checks Forgory Other Fraud Fraud- Confidence Game Fraud• False Statement Fraud- Illegal Use Credit Caros Fraud. Impersonating Fraud - Insufficient Funds Check Fraud • Swindle Fraud By Wire Fraud and Abuse • Con'lputer Frequent House Ill Fame Gambfing Gambling Device Gambfing Device - Not Registered Gambling Oevioe - Possession Gambling Oevioe. Transport Gambling Goods Gambling Goods - Possession Gambling Goods - Transport Gang Activity Gov'\ Official Not Peff. Duties Gratuity Gratuity • GMng Gratuity - Offefing Gratuity - R9CeiVlng Halucinogen Halucioogen - Distribution Halucinogen- Manufacturing Haludnogen - Possession Haluclnogen - Sell Harassing CommunicaOOn Harboring Escapeo/Fugllive Health - Safety Heroin Heroin• Possession Heroin· sea Heroin - Smuggl8 Hit aod Run Homlcldo.Wlllful KIII-P�lco Officer Homicide-WiUful Kill-Public Official Homosexual Act With Soy Homosexual Act With Girl Homosexual Act With Man Homosexual Act Wrth Woman Human Slavery or Trafficfong loont�y Theft Illegal Arrest Illegal Entry Illegal Reentry Incendiary Device - Possessk>n 2020-ICLl-00006 598 STATE SUDAN SURIN SWAZI SWEDE SWITZ SYRIA TAIWA TAJIK TANZA THAil TOGO TONGA TRINI TUNIS TURKE TURKM TURKS TUVAL UGAND UKRAI UAE UK us UNKNO URUGU USSR UZBEK VANUA VENEZ IIIETN \IIRGI WALLI WSAHA YEMEN YUGOS ZAMBI ZIMBA STA - ERO-SI. Albans, YT Sub Office STC- ERO- South Texas. TXDet&ntlon Facillly STG•ERO •Stewart. GA Sub Office STL-ERO-Si. Louis, MO Sub-Office STO • ERO· Stocktoo. CA Sub Office SXC - ERO-Sioo){ City, IA Sub Office SYR • ERO -Syracuse, NY Su.l>-OffiOO TAC -ERO-TACOMA.WA Sub Office TAL. ERO. Tana11as-. FL Sub Office TAM· TAMPA. Fl. DOCKET ODNTROL OFFICE TFI -ERO -Twin Falls, Idaho Sub Office TLS -ERO-TULSA, OK SUB-OFFICE TRC-Sou1h Texas Famity Residential Center rue-TUCSON, AZ. DOCKET ODNTROL OFFICE TXA- ERO - Texarkana.AR Sub Office VEN -ERO -Venlura, CA Sub Offioe VRK • VARRICK, NY. SERVICE PROCESSING CENTER (DOCKET ODNTROL OFFICE) WS -ICE ERO Shtevoport Sub Office WAS -WASHINGTON, DC, Docket Control Office WCD - ERO - SALISBURY, MD SUB OFFICE WCT -ERO -Waco, lXSub Office WHP•ERO•White Plains. NY Sub Office WIC -ERO-Wichila, KS Sub-Office WIL ·ERO· Wilmington, NC Sub Office WNT - ERO - Wenatchee.WA. Sub Office WPD -ERO - Stuan, FL Sub Office WPM -ICE ERO WALPOLE Sub Offioe WSM -ERO -Westminster, CA Sub Office YAK· ERO· Yakima. WA Sub-Office YOU - ICE ERO YOUNGSTOWN Sub Off'"" YRK - ERO - YORK. PA SUB-OFFICE YUM -ERO -Yuma, AZ Sub Office lncecidiary Device-Teadwlg Use lnoondlary D8Vice-UsJng Incest With Adult Incest With Minor l.noome Tax Indecent Exposure Indecent Exposure to Adult Indecent Exposure to Minor lnte,sta. T,ansp. Sto4en Vehiele Intimidation Invade Privac:)' K98plng House Ill Fame Kickback Kickback -Giving Kickback - Offe!Tlg Kickback -Recei._,;ng Kidnap Adult Kidnap Adult For RaliSOn'I Kidnap Adult To Sexually Assault Kidnap Hostage For Escape Kidnap Minor Kidnap Minor For Ransom Kidnap Mtnor To Sexually Assault Kidnap Minor--Nmparental KidNIJ) Minor-Parental Kidnap-Hijack Aircraft Kidnapping Larceny Larceny• From Auto Larcen)' - Fron, Banklng-T)'pe Institution Larcen)' - From Bulldlng Lao::eny-From Coin Machine Larcen)' - From Interstate Shipment Larceny• From Mails Larceny -From Shipment Larceny. From Yards Larcen)' -Parts from Vehicie Larcen)' -Pos1a1 Larceny On US Gov't Reseives Lewd/Lascivious Acts with Minor Licensing - Registration Weapon Licensing VW>latiorl Liquor Liquor -Manufacturing Liquor - Possession Liquor- Sell Liquor-Transport Liquor Tax Louery Lottery - Ope.-atrtg Lottery - Rumer Mall Fraud Making False Report Mandato,y R&lease VIOiation Marijuana Marijuana (describe offel'\Se) Matljuana -Possession Marijuana -Sell Marijuana-Smuggle Military Military Oes,ettl(>(I Misconduct - Judicial Officer Molestation of Minor Money Laundering-Remarks Morals •Deceric)' Crimes Mulder I Homicide Narcotic Equip -Possession Neglect ChUd Neglect Disabled Neglect Elderly Negloct Family Non-payment of Alimony Non-$Uppof1 of Parent Obscene Obscene Communkation Obscene Materia I•Malling Obscene Material Obscene Malerial -DtSltibution Obscene Material•Manufacturilg Obscene Material -?ossession Obscene Material - Sell Obscene Material -Transport Obstruct Obstruct Corresp. (postal violation) Obstruct Criminal lrrvest Obstruct Police Obstructing Court Order Obstructing Justice Ope<1ing Sealed Communicatioll Opium Or Derivatives Opium O r Derivatives • PossesSKMl Opium Or Derivatives . Sell Opium O r Oerivati,.,es•Smuggle Parole Violation Pass Countertected Pass Forged Peeping Tom Perjury Perjury -SubOmation Of Pod(elplcking Poss. Tools For Forgery!Covnterfeiti� 2020-ICLl-00006 599 Possess of fraud. lmmig. Docs Possession Counterfeited Possession forged Possession Of Weapoo Possession Stoien Property Possession Sto$en Vellide ProbaHon Violation Prowre for Prostitute (pimping) Procure for Prostitute.Adult Proa.,re for Prostitute�Minor Property Crimes Prostltutlon Public Order Oirnes Public Peace Purse Snatching - No Force RICO Act Rape • Disabled Rape· D�uced Rape· Eld8!1y Rape• Gun Rape • Remarks Rape • Strongarm Rape With Weapon Receive Stolen Property Receiving Slolen Vehicle Refusing To Aid Officer Resisting Offioer Riot RiOt • Engaging in R10t - Inciting Riot - lnterfet'e Firearm R�t • ln!erfere Officer Rcbbety Sabotage Sale Of Stoleo Property Sales Tax Sedition S9ductlon Of Adi.lit SeJective Sefvice Selling Weapon Sex Assault Sex Ass.:tult . Camal Abuse Sex Assault· Disabled Sex Ass-auJt - Elderly Sex Assault • Sodomy-Boy-Gun Sex Assault - Sodomy•Boy-Strongarm Sex Assault - Sodomy-Boy-Weapon Sex Assault - Sodomy-Girl-Gun Sex Ass.:tult - Sodomy-Girl-Strongarm Sex Assault - Sodomy-Girl-Weapon Sex Ass-auJt - Sodomy-Man-Gun Sex Assault - Sodomy--Man--Strongarm Sex AssauJt - Sodomy-Man-Weapon Sex Assault - Sodomy-Woman-Gun Sex Assault - Sodomy-Woman-Stron,garm Sex Assault - Sodomy-Woman-Weapon Sex Offender Reglstr. Violation Sex Offense Sex Offense • Disabled Sex Offel'lSe - Elderty Sex Offen.se Ag. Child-Fondling Sexual Assault - Drug-Induced Sexual Exp4oitation of Minor Sexually VIOiate Human Remains/Necrophilia ShopUffing Simple Assault Smuggle Cootraband Smuggle Coob-aband Into Ptl""' Smuggle To Avoid Paying Duty Smuggling Smuggling AllollS Sovereignty Spor1S Tampe�_______________ Subject ID Jn- \/"'7\lr\ j Processing Disposition: Other RCA Look-Up .. c:s� #� 1/h \{7\iF ! c:se c;';,i;go,;, SF• oo'::ket: HOU .'." Closed ·oock;t Book In Date: 03/07/2014 Detention Loca�on: HOU - HOUICDF Assigned Unn: NIA Assigned Bed: NIA Detention Classification: Low Attorney Notified: No Local Code: NIA Book Out Dale: 03/11/2014 Type: R • Released Treat As Juvenile: No Current I Active Alerts I I I Transgender Detention History F.O. of Removal [ Criminal _J Hernandez, Jeffry 206 418 141 HistoryDetention History for JEFFRY HERNANDEZ I I FILTER BY ENCOUNTER/ SUBJECT 10 FILTER BY CURRENT/ HISTORICAL RECORDS FILTER BY CASE NUMBER custody) I � Show Current Detention Records (currently in I Book In USM Date 05/16/2018 1047 I I I I � Show Historical Detention Records A-Number 206 418 141 Subject ID b)(7)(E) b se# Detention Location Book Out Date Release / Book Out � CIB - CIBOLA COUNTY CORRECTIONAL CENTER 05/25/2018 0332 Released - Died 05/1512018 1515 206 418 141 EPC - El PASO SPC (IHSC) 05/16/2018 0800 Transferred - EPC 05/13/2018 1118 206 418 141 SND - SAN LUIS REGIONAL DET CENTER 05/15/2018 1200 Transferred • SND 03/0712014 1709 206 418 141 HOU - HOUSTON CONTRACT DET.FAC. (IHSC) 03111/2014 Released • Removed 03/07/2014 1707 086 859 115 HOU • HOUSTON FO HOLDROOM 03/0712014 1708 Transferred - HOU 05/1412009 1700 086 859 115 DAL • ROLLING PLAINS DETENTION CENTER 05/15/2009 0649 Released - Voluntary departure - I 1131 I I Records with the USM indicator signify detainees that are under the custody of the U.S. Marshals but are detained by ERO. United Stales Department of Homeland Security (OHS), U.S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO) I Release EARM 5.50 l(b)(7)(E) 2020-ICLl-00006 638 8/1/2018 !(b)(6); (b)(7)(C) 4 Jun 2018 21:13:37 +0000 r)(6); (b)(7)(C) From: Sent: To: Cc: Subject: FW: HERNANDEZ Detainee Death Review Info Request Attachments: Medcial info.pdf, Cibola transport packet Hernandez.pdf, ICE Detainee Hernandez A206418141.pdf, hernandez.pdf, File A206 418 141 (LEFT SIDE).pdf, File A206 418 141 (RIGHT SIDE, PART-1).pdf, File A206 418 141 (RIGHT SIDE, PART-2).pdf Good Afternoon, Please see attachments being submitted in response to your message below. As a reminder, it appears that I do not currently have approval to gain entry into the SharePoint site sent to me. Thank you I ](b)(6); (b)(7)(C) Assistant Field Office Director ERO El Paso field Office 915-856-(b)(B); (office) 915-726- �)(7)( ( cell) tb)(6); (b)(7)(C) From:!(b)/6): (b)(7)(C) Sent: Monday, June 04, 2018 10:07 AM To: �b)(6); (b)(7)(C) Cc: l Subject: l(b)(6); (b)(7)(C) !Detainee Death Review Info Request -:---;;;:::;::;;;;:::::;;:::;:::;;;:;:::;:;:;:::::;:---:-----::---:--:--:----:--::-:----� Good morning AFODkb\/6\ /b\/7\/C\! As you know, our office will be reviewing the death of detainee HERNANDEZ who was in ICE custody at the Cibola County Correctional Center (CCCC) from May 17 - May 25, 2018, and who died on May 25, 2018. I will be the Team Lead for the review. Attached to this email is a request for information related to HERNANDEZ. We ask that your office provide the requested information by June 8, 2018 via SharePoint (the link is below). Please let me know who you would like to designate to upload and I will give them the appropriate permissions. If you have any questions about the request, please let me know. After we review the documents, we'll send a preliminary witness list of individuals we would like to interview during our onsite review. I'll also be following up with a request for information from San Luis and El Paso Processing, where the detainee was also held in custody before arrival at CCCC. l(b)(7)(E) 2020-ICLl-00006 639 Respectfully, l(b)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 732 (b)(6); Cell: (202) 270- �p !/bl/6): (bl/7l/Cl l( 2020-ICLl-00006 640 ICE Health Se�,ice Co�p� • 1 In-Processing Health Screening:,�.Qrm . This form will be sent to the medical clinic after it is completed. lnterpreterprovided? OYes [8]No INT#: _______ Section I: Ask The Detainee (Check the appropriate box) OYes 1. Have you seen a doctor in the past year? Today's Date: ., 05/11/2018 [8]No If YES, for what? _________________ OYes [8]No 2. Are you having any pain? If YES, for what? _________________ 3. Have you been hospitalized in the past 6 months? OYes [8]No If YES, for what? _________________ OYes [8]No 4. Have you ever been treated for problems with drugs or alcohol? If YES, when, where and for what? ______________________ Do you now have or have you ever had any of the following? OYes �No 5. Your skin break out in bumps, or trouble breathing after taking medication? 6. Sores on your privates, or a drip from your privates? 7. Trouble peeing? 8. Fits or seizures? 9. The whites of your eyes or your nails tum yellow? 10. Persistent cough (of more than 3 weeks duration)? 11. Hemoptysis (coughing up blood)? 12. Not been able to eat with a significant weight loss? OYes OYes □ □ □ �No Yes �No Yes OYes 13. A persistent fever? OYes 15. Weakness/lethargy (tired)? 16. Are you afraid you might lose your mind or go crazy? OYes 14. Night sweats? [8]No OYes Yes �No �No �No �No OYes (g]No OYes [8]No 17. Are you afraid you might hurt or kill yourself or others? OYes OYes 18. If female, are you pregnant? ....__.. ....__.. (8]No (8]No Please mark any bruises, scars, cuts or other marks or distinguishing physfcal characteristics in the diagrams below, and notify the !HSC medical officer ii you feel tti'at the detainee needs any kind of medical evaluation. (8]No �No Section II: Your Observations of The Detainee (Check the appropriate box) Does the detainee appear to be: OYes �No Not doing what you tell him to do? OYes �No Acting crazy or strange? OYes �No Skin broken out in bumps/rash? Section Ill: Detainee Sent To (Check the appropriate box) [8]General population. b)(6); (b)(7)(C) n Isolation until medically evaluated OYes (8]No Malnourished? OYes �No Sweating a lot? OYes □ (8]No Shaking/tremors? ,t·., f I Print' Last Name: / HERNANDEZ RODRIGUEZ First Name: ROY ALEXANDER A#: 206 418 141 Country of Origin: HONDURAS Date of Camp Arrival (DCA): 05/09/2018 DOB:' 02/1811985 Medical Clinic: MOBILE MEDICAL GROUP Sex: Male 10/2010 □ OYes t Page 1 of 1 2020-ICLl-00006 641 Yes OYes General population with referral to p,e�lcal care , he form IHSC Form 794 • • I ig]No Cuts or bruises? ig]No Needle tracks? �No A handicap? 0 Referral for immediate medical care l(b)(6); (b)(7)(C) M·,n.::ime of individual completing the form 'I,,, . \, .. . . .. , . ' .... - .· ' .. \ Date NEW PATIENT COMPREHENSIVE EXAM PatientName �J'I.�. �"'l':"J h l Vr l.Jiwif><.!,.,. 1 � L,. cc . I Location Timing Al�-4i Medications _I; , A) � SYS________ A# �Lf (5(c..f (· Severity Quality _______ Duration' Context _______ current medlcadons A/vCl).A- Allergies Past Med Hx - Allergy/Imm:_____________ l - GU: c3 . � s �'::ro.. htv II II II _MS: Skfn: I .. 1 �ev!ewed. No.prior Illness Past Surgical Hx �,�o,g;cal Social H - - c..9 /�l.._ �� I'� \......,_ � _ Neur::e:f?� _ Psych: ______________ '"'':!!''" ""'$� 1� ,S2.Revlewed and found noncontributory Family Hx �lewed and found noncontributory Endocrine: ��" ------------=--- / - Heme Lymph: ____________ � Systems reviewed, negative except as noted above : - Examination: VS: (3+) T General: Qfr r ( �70 e.NICl:A.� - r;t{ BP '- R p /� / �"\ /€, Satft Wt ___ ; c:1WD/WN; _2-No distress; _Obese; Eyes:-----------------------�· �rmal lid/conjunctiva Inspect on; _PERL E/N/M/T: ________:___________________________ __lkc; Normal llps/teeth/gums; �ormal oroph�rynx rmal external inspection;_ Normal TM's;· · · �pie; JZ.Normal appearance; _ No JVD; _ No Thyromegaly Neck: f. "'-�"" ------------------�i --'?ormal effort; -�s CTA bilaterally ·-=--� Respir-atory: -�"--""'f ---1--�-----' CV; ____________________,· -2tRR; __0.Jo murmur; _9ulses equal bllateral radlal arteri1:;s GI: ________...:...._________ __..J· �n-tender abdomen;�on-distended abdomen;_ No HSM Lymphatics:------,,--,--------�· � cervical ly�hadenopathy; � axillary lymphadenopathy · _bormal gait; �rmal inspection of digits/nails __54o acute rash visible; ormal palpation of skin Musculoskeletal Skin: Neuro:_______.:...._____________,· _ CN ll�XII grossly lntact;�ormal sensation; _Normal DTR Psych: ________,;.;.,____________. _Oriented x 3; gpropriate mood/affect; _Memory Intact · Tests/Procedures/Suoolies: I - HCG - FS JI _Strep - UA: I -- SG: -- Pro: -Blood: -- Leuk: -- Ket: -Gluc: __. Nit: - ECG: - _Splinting: ., Other: fa _ Medically cleared for transport and incarceration [Reflects: comprehensive hlnory and erformed In austere environment, ri5k of compllcation Involving lmmlg111tlon, detention, and paucity of past history) b)(6); (b)(7)(C) Provider Sllmature at medically cleared for transport and incar'cefc1tlon I Date 2020-ICLl-00006 643 Provider Name Division of Immigration Health Services Pharmacy Benefits Letter Dear Pharmacy Provider and Jail/Custodial Facility: The Division of Immigration Health Services (DIHS) provides limited prescription drug coverage for individuals in the custody of the Immigration and Customs Enforcement (ICE), the United States Border Patrol (USBP) and the Office of Refugee Resettlement (ORR) through the Script Care, Ltd. Pharmacy Network. Please note the plan does not use a standard ID card. Please submit the prescription using the ENFORCE Event Number. Precede the Event Number with 'BP'. Example: !!bl/7\!El L Please submit claims electronically as follows: BLN Number: 004410 Processor Control Number: DIBS ( I Detainee Name*: HERNANDEZ RODRIGUEZ Detainee Number*: A# 206418141 ROY ALEXANDER BP SYS fb)(6); (b)(7)(C) I Today's Date*: 05/11/2018 Detainee DOB*: 02/18/1985 Group Number**: DillSUSBP (U.S. Border Patrol) * Required Information -To be completed by Jail/Custodial facility. For Detainee Number, please utilize the Detainec's 9-digit Alien ID Number. ** Jail/Custodial facility responsible for providing to the pharmacy. For "Group Number", please enter the DIHS facility code for your Jail/custodial facility. Ir you are unsure what DIHS facility code to use, please call your DlllS Managed Care Coordinator. If you have any questions regarding pharmacy prior authorizations or claim submission, please contact Script Care's Pharmacy Help Desk at 1-800-880-9988. Thank you, Division oflmmigration Health Services l'' '" 2020-ICLl-00006 644 C,)· Scripps :' HERNANDEZ - RODRIQUE, ROY A DOB: 02/18/1985 MRl'llllh\/R) /h\/7\/r.\ I 485 H Street Chula Vista, CA 91910 0&11111e ED . ,.,· ..... , · . .'• • : ;,•• " - -_.:.. : •. L'.•,•l', ,. , ' :.-,:·.: ... . M/33 1111m 1 m mn 001 rn11 �ru 11111 mu mu � 1111 SCRIPPS MERCY HOSPtT kb)(6): (b)(?)(C) PHYSICIAN'S AFTERCARE INSTRUCTIONS ACfTj .... Pi(h\(R\ (h\/7)((:\ AL, CHULA VISTA . □ Wound Cleaning □ .Bem.oval of Stitches/Staples □ Dressings □ Splint Or Cast □ Crutches D Tetanus Booster □ EKG □ Labs__ �-rays__ ------------------------------------------------------- am Breathing Treatment Intravenous Fluids Stitches/Staples Medications: 0th er: □ □ □ □ Return to Regular Work/School. Date: ______ □ Return to Modified Work Date: ---- Duration: -----Modification --------------==----------,,,,::,--------□ Unable to return to work/school for __ days. □ No P.E. __da,ys. D Return Visit: ___ Call today to arrange for a follow-up appointment in __ days. DrJClinic:,_______ Phone: ____ C □ If symptoms persist more than __ days, contact your physician or clinic. □ Wound check in __ days here or by your doctor. □ Stitches/Staples out in __ days here or by your doctor. □ Discharged. No further treatment anticipated. See your physician or return to the Emergency Department � new symptoms develop. TO FIND ANOTHER PHYSICIAN, CALL THE PHYSICIAN REFERRAL Service at 1-800-SCRIPPS (1-800-727-4m) Domestic Violence Ho�ine: 1-800-�99-9fiFE C ISIS COUNSELING SERVICE: '1 (800) 479-3339 :J:' IMPRESSION: C } -f' OTHER INSTRUCTIONS: Refer to Home Care --r IMPORTANT: the examination and treatment you have received in the Emergency Department has been rendered on an emergency basis only. Your emergency care is not intended to be a substitute for, or an effort to provide, complete ongoing care. It is essential that you carefully follow the instructions listed above. IN THE EVENT THAT YOUR PROBLEM WORSENS OR NEW SYMPTOMS DEVELOP, AND YOU ARE UNABLE TO ARRANGE PROMPT FOLLOW-UP CARE, YOU SHOULD CALL OR RETURN TO THE EMERGENCY DEPARTMENT. TELEPHONE (619) 691-7290. I HAVE RECEIVED AND UNDERSTAND THE INSTRUCTIONS INDICATED. I will arrange for follow-up care as instructed a(b)(6); (b)(?)(C) A TH PATIENT DATE/TIME PATIENT OR REPRESENTATIVE 2020-ICLl-00006 645 DATE/TIME •□CIN CV 330-7010-9258* CV�7010-9258 (11/20i06) UNITED STATE DTVI 10 PUBLIC HEALTH SERVICE OF lMMlGRATIO TR •ATME HEALTH ERVICES (DIHS) TA THORlZATION REQUE T(TAR) Immigration Health erviccs 1220 L Street. W · PMB 468 · Washington, 0.C. 20005 Phone 1-888-718-8947 · Fax 1-866-256-8172 YE. ls this request n T1\R APPEAL (l'lcnsc circle one•) If YES, it is required that you provide lhe T/\R UMBER you are appealing: SAN YSIDRO PORT OF ENTRY Detention Facility•: Address": 720 E. SAN YSIDRO BLVD City• SAN YSIDRO Last amc•: Alien ID*: ( OJ HERNANDEZ RODRIGUEZ 206418141 Diagnosis/ ymptoms• Course ofTreat111en1•: DETAl1 EE 11 FORM TION tnte•: Date orBirth : 05/09/2018 Country orOrigin•: REA ON FOR REFERR. L REOUE T ·t. ,. (619) 662@.i@J (619) 662-7442 CA Zip•: ROY ALEXANDER First*: 02/18/1985 "' Camp Arri al Date•: Phone#*: ex•: Male (8) HONDURAS Female 92173 0 HIV POSITIVE NO MEDS FEVER CHILLS T.B RULE OUT CLEAR FOR INCARCERATION AND TRAVEL A"ITESTATIO l(b)(6); (b)(?)(C) CPT/COT: USTODV 18 attest that the inforn1ation provided on this __ _O_D_A_Y-'S_D___ rE...,.•A_ ( T l TAR form is correct 10 the best or m knowledge and that the detainee i · not a U .. Citizen and is/was in cu tody oft he (check one•): � US Border Patrol (BP)- Please circle one of the following and provide: Fl or Event// or Log/I SY l(b)(B); D D from l b)(B); (b)(?)(C) L Resettlement (ORR) /2018 to IN CUSTODY (CUSTODY E D DAT·•) SCBPO (TITLE*) E') Provider's Name .. : I �ustoms EnforcementiDetcntion nnd Removal (ICE/ORO) PROVIDER OF MEDI D OTIIER SERVICES ------------------SCRIPPS HEALTH Provider's Phone Number .. : (619) 691-7000 DIH (619) 662t?1\�1;1 Pro idcr's City*": Specialty*: EMERGENCY DEPT CHULA VISTA Provider's tote**: AUTIIORIZATION A {To be completed by Dlf/S 0 DI! I Managed Care Coordinator (MCC): MCC TAR Action: MC Comment: Approved D (S1'g110111re) Denied D Pended Onie: 0 Please provide a copy of1J1e ''Approved" TAR lo the llcalth Sm'icc Provider on-emergent heuhh services will not be paid without an approv'ed TAR issued prror to hcahh sen•ices being rendered. Emergency health services require TAR submitted within one business day at1cr bc111g sought. A separate TAR will be required for hc.ilth services beyond and 011tsidc the scope of the original authorized TAR. For health cure claim status inquiries, call 1-800-479-0523, To appcnl H TAR tlccision of Dll I 10 1101 authorize a service, n detention facility must submit a WAR Appeal through the TAI( process anu include the following informatio,r n) "'TAR Appeal", b) TAR number und other information from TAR being appealed, c) rcque ·t action, and c)justificntion for the requested ac1io11. For furll1er guidn11cc and information please visit our website at: www.icchcolth org or contact the O11 IS' Managed Cnre Coordmaturs at 1-888-718-8947, M - F. 81\M -6 PM EST, Revised 20050421 "Failure l-4- I t 35 0 I VEHICLE: IC: Place a ✓ to Indicate an inspection was completed or write NA if item is not applicable DD: Place a✓ io Indicate defects discovered and explain in "Defects Discovered Summary" section below PRE DD ✓ ./ ITEMS IC Brakes Operable Brake Lights Operable Head Lights Operable Turn Signals Operable Emergency Flashers Operable Tire Levels and Condition Acceptable Lug Nuts IC POST DD ./ ./ ✓ ✓ ✓ ,I Wheels and Rims I Date I VIN# Employee ID Ending Mileage ITEMS Horn Operable Steering Operable Rear Vision Mirrors Windshield Wipers Operable Fuel Level Acceptable Oil Level Acceptable Scratches/Dents Present Coupling Devices 8-12A 05/17/2018 l(b}(6}; (b}(?}(C} �, 2 Z ;fl IC PRE DD IC t/ ,/ ,;/ I POST DD / / / ./ ✓ TRAILER: IC: Place a✓ to indicate an inspection was completed or write NA if item is not applicable DD: Place a ✓ to indicate defects discovered and explain In "Defects Discovered Summary" section below ITEMS IC Brakes Brake Lights PRE DO IC POST DD Head Lights Turn Signals ITEMS Rims Air Line Connections, Hoses, Couplers IC PRE DD IC POST DD King Pin Upper Coupling Device Rails or Support Frames Emergency Flashers Tires Tie Down Bolsters Sliders or sliding frame lock Lug Nuts Wheels Locking Pins, Clevises, Clamps, or Hooks SECURITY & MISCELLANEOUS: IC: Place a ✓ Lo indicate an inspection was completed or write NA ii item is not applicable DD: Place a ✓ to indicate detects discovered .iill! explain in "Defects Discovered Summ_ar�y_" _se_c_tio_n_b_e_lo_w_________� ----�----� ITEMS IC Security Screen Secure Contraband Search - If found, explain below Interior Clean PRE DD IC POST DD ITEMS Emergency Equipment Present Lockln Devices Operable Driver Possesses Llcensu re IC PRE DD IC POST DD •1F ANY OF THE ITEMS ARE FOUND INOPERABLE OR CONSIDERED A SAFETY HAZARD., NOTIFY THE SHIFT SUPERVISOR IMMEDIATELY." DEFECTS DISCOVERED SUMMARY: l /f/4AK CONTRABAND DISCOVERED SUMMARY: �--------Driver Signature (b}(6}; (b}(7}(C} c/2�a./ I 1--------------------------------------' THIS SECTION TO BE COMPLETED BY MAINTENANCE/REPAIR CENTER PERSONNEL ONLY: NOTE: Repair Center personnel may provide a receipt outlining work completed in lieu of signing this form. Choose One: D Defects noted above have been corrected COMMENTS: OR D Defects noted above do not need to be corrected for safe operation of the vehicle I Title Printed Name 01/02/13 Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 650 I FACILITY: ] DATE OF TRANSPORT: TRANSPORT ORDERS 9-181: I CIBOLA COUNTY CORRECTIONAL CENTER J 05/17/18 D MASS COURT TRANSPORT: [XI NO YES If yes, attach Escape Flyers and complete Sections Ill & IV only of this form. SECTION I - TRANSPORT LIST (To be completed by the Records Department or other department as identified in policy 9-18)· Housing Height Criminal Charge or Custody I.D.# Date Inmate/Resident Name Assignment Conviction (highest current Classification Of charge/conviction) Birth Hernandez, Jeffry R01 002 I l/b\/6): 02/18/1985 I TOTAL NUMBER OF INMATES/RESIDENTS ON TRANSPORT: TRANSFERS: (Any permanent transfers to other facility or agency?) ALERTS: (i.e. escape risk, combative, etc) Inmate/Resident Name Hernandez, Jeffry YES-0 NO-[XI I NO- □ Inmate/Resident ID# rb)(6); (b)(7)(C) I 5'3" Low Purpose of Transport (i.e. court, medical, transfer, appt, etc.) Medical 1 01 If "YES", the Records Manager (or other designated department) will ensure the inmate/resident's institutional file and Medical file are trans orted with the inmate/resident. YES-[XI If "YES", complete section below. ALERT Comment: New Intake DATE: (b)(6); (b)(7)(C) 05/1712018 *If additional space is needed to accommodate inmates/residents on this transport, this page may be duplicated / copied. The Transport Supervisor will ensure to number all pages accordingly when reviewing the Transport Order. Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 651 7/10/13 PAGE OF 9-18E TRANSPORT ORDERS SECTION II - HEALTH SERVICES (To be completed by the Health Services Department): Are any of the female inmates listed in Section 1 currently pregnant? D Yes [ZI No (If yes, list below and include any special instructions) Special Instructions: (e.Q. medications, physical limitations, special needs, etc.): Inmate ID# Soecial lnstructions/Reauirements: Inmate Name Ix QHCP Printed Name l(b)(6); (b)(?)(C) If requesting reduced restraints ror memcaI purpose, must be signed by HSA or Physician also: I I QHCP Signature Printed Name & Title I)( l(b)(6); (b)(?)(C) r ::signature I >·17-/� *Note: If special medical instructions are listed above, the Transportation Officers will be responsible for meeting with the Health Service Department prior to the transport. SECTION LI I - TRANSPORT REQUIREMENTS (To be completed by the Transportation Supervisor): I VEHICLE REQUIREMENT (i.e. bus, van, etc.): I Van I NUMBER OF TRANSPORT OFFICERS REQUIRED/ASSIGNED: I CHASE VEHICLE REQUIRED: I NO-� I YES- □ MEALS REQUIRED (if the transport lakes place during meal time): NO-� YES-0 [ 2 lf"YES', NUMBER OF CHASE VEHICLE OFFICERS ASSIGNED: I If "YES". the Transportation Officers shall be responsible for obtaining sack lunches for all inmates/residents and em lo ees. SECTION IV - AUTHORIZATION: TRANSPORT SUPERVISOR Assistant Shift Su ervisor or above DATE: 05/17/2018 *The Transport Supervisor will ensure to number all pages accordingly when reviewing the Transport Order. WARDEN/ADMINISTRATOR OR ADO 05/17/2018 {if not available for sionature, note the Date & Time aooroval received) DATE: Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 652 7/10/13 PAGE OF TRANSPORT ORDERS 9-18E SECTION IV continued - AUTHORIZATION: Additional instructions and/or comments from the above authorizing staff only: Use proper restraints required. Unscheduled Appointments: In the event a non-emergency transport is required with minimal or no prior notice, the highest-ranking official will coordinate the transport, to include notification to the Dutv Officer prior to the transport. Date/Time: Authorization Received by: I I I SECTION V - TRANSPORT OFFICERS ACKNOWLEDGEMENT Transport Officer Signature: Printed Name & Title: Transport Officer Signature: Printed Name & Title: b)(6); (b)(?)(C) Transport Officer Signature: Printed Name & Title: Transport Officer Signature: Printed Name & Title: I I DATE: I DATE: I DATE: DATE: Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 653 I 5 - I 7- /,,r I 7/10/13 PAGE OF Facility Name Location of Post Date Cibola County Correctional Center [,l,i.,{4 (1.fr•�uf �fP,kf �� 17. 1h c-/4: C RESULT OF CUSTODY REDETERMINATION On _______, custody status/conditions for release were reconsidered by: □ Immigration Judge □ DHS Official □ Board of Immigration Appeals The results of the redetennination/reconsiderationare: Release • Order of Recognizance □ No change - Original determination upheld. □ Release - Personal Recognizance □ Detain in custody of this Service. □ Other: ________ Bond amount reset to_______ □ □ (Si�of off,ccr) Fonn 1-286 (Rn. 08/01/07) 2020-ICLl-00006 675 Warrant for Arrest of Alien U.S. Department or Homeland Seeutty File No. PINS#: A206 418 141 Bvent No: L.;..(l b...;..)('-' 7)..;_ (E..;_) ___....J 17851616 Date: Karch 7. 2014 To any officer delegated authority pursuant to Section 287 of the Immigration and Nationality Act: From evidence submitted to me, it appears that: JBIFRI ALBXAHDBR KBRNANDBZ-RODRIGtl'BZ (f�II """"'of alim) an alien who entered the United States at or near LARXDO, 1'UU ------�-,,�------- on _J_an_ua_rr __2_3_,�2_0�14 _____ is within th: country in violation of the immigration laws and is (Diuc) therefore liable to being taken into custody as authorized by section 236 of the Immigration and Nationality Act. By virtue of the authority vested in me by the immigration laws of the United States and the regulations issued pursuant thereto, I command you to take the above-named alien into custody for proceedings in accordance with the applicable provisions (b)(6); (�)(?)(�) regulations . .......,_________ Qom-i SDDO Certificate of Service on Narcb 7 • 2 o 14 at o 4 : 53 PM Served by me at eouuoN, 'l'BXAS I certify that following such servic� the alien was advised concerning his or her right to counsel and was furnished a copy of this warrant. (b)(6); (b)(7)(C) DDOKTATI01f OJl'l'Ic:Ba 2020-ICLl-00006 676 I-200 Continuation Page for Form ________ U.S. Department of Homeland Security Alien's Name JBIFRI ALEXANDER BJ:RNANDEZ-RODRIGD"BZ File Number A206 418 141 Bvent No I l(b}(?)(E} OTBBR ALIASBS KNOWN BY ---------------------- Date 03/07/2014 BBRBANDBZ, JBPRBH Signature l(b)(6}; (b}(?)(C} I I Til1e DKl'OlTATION OFFICD 2_ Pages 2_of __ __ Form I-83 I Cootinuarion Page (Rev. 08/01/07) 2020-ICLl-00006 677 Notice of Custody Determination U.S. Depar1mmt ofHomtlaud Stt11rity DaHAm>U-IIODllCMIZ, JJnPIU ALBDJID•II AXA, RBAKAlfDBZ, J11nD Event No: )(7)(E) File No: '=A=___,.......,._....,...__, Date: 03/07/2014 l{b){6): (b)/71/C) PIH: 1785161' 1101JBTOII, TUAS, 77032 Pursuant to the authority contained in section 236 of the Immigration and Nationality Act and part 236 of title 8, Code of Federal Regulations, I have determined that pending a final detennination by the immigration judge in your case, and in the event you are ordered removed from the United States, until you are taken into custody for removal, you shall be: □□ LY detained in the custody of the Department of Homeland Security. ---- �leased under bond in the amount of$ released on your own recognizance. D You may request a review of this determination by an · · grationjudge. · (b)(5); (b)(?)(C) !J You may not request a review of this determ tionjudge because the Immigration and ty Nationali Act prohibits your release from cust SI)DO (T"llle of IWlmiad aflior.r) RO'QBTOJf, TBXU (O � location) .61 I do il do not request a redetermination of this custody decision by an immigration judge. JlJ I acknowledge receipt of this notification. RESULT OF CUSTODY REDETERMINATION On _______,, custody status/conditions for release were reconsidered by: D lmmigration Judge □ DHS Official □ Board of Immigration Appeals The results of the redetenn.ination/reconsiderationare: D Release· Order of Recognizance □ No change - Original detennination upheld. y □ Release • Personal Recognii.ance □ Detain in custod ofthis Service. D Other: ________ □ Bond amount reset to_______ (Slp1111tor am-) Fonn 1-216 (Jffl'. 08/01/07) 2020-ICLl-00006 678 Warrant for Arrest of Alien U.S. Department of Homelaud Security ____ File No. A2D6 4.18 141 Event Ho I �(b)(?)(E) .__ Date: March 7, 2014 FINS f: 17851616 __. To any officer delegated authority pursuant to Section 287 of the Immigration and Nationality Act: From evidence SJbmitted to me, it appears that: JEIFRI ALBXANDER IIBRNANDBZ-RODR.IGUEZ (l'u.11 mmc or alic:i) an alien who entered the United States at or near LAIUtt)Q,'l'BXAS ---------..::::t""________ on _J_an_u_a:ry __2_J_,........,2,.,..,10 ,....4_____ is within the country in violation of the immi�tion laws and is (bite) therefore liable to being taken into custody as authorized by section 236 of the Immigration and Nationality Act. By virtue of the authority vested in me by the immigration laws of the United States and the regulations issued pursuant thereto, I command you to take the above-named alien into custody for proceedings in accordance with the applicable provisions < (b)(5J; (b)(?)(C) iulations. SDDO (Tht) Certificate of Service on March 7. 201-1 at 04: sJ PM Served by me at B017BTOH, TBXAS I certify that following such service, the alien was advised concerning his or her right to counsel and was furnished a copy of this warrant. �)(6); (b)(7)(C) :DSPOttAnOM OFFICU. Fonn 1-10G (l\n. DWll'07) 2020-ICLl-00006 679 U.S. Department of Homeland Security . Alien's Name JEIFRI ALEXANDER HERNANDEZ-RODRIGUEZ OTJIBR ALIASES ICNOWN BY ---------------------- I-200 CootiD.uahoo Page for Form _______ File Number A206 418 141 Event No: l(b)(7)(E) Date 03/07/2014 HERNANDEZ, JEFREN Signature l(b)(6); (b)(?)(C) l Title DZPORTA'r.1011 OFFICEJI. 2 2 ___ of ___ Pages Fonn 1-831 Continuation Page CR=v. 08/01/07) 2020-ICLl-00006 680 Online Detainee Locator System Oulinc lh:t a i 1 1 c: c: l . 1 1 L· ,1 1 m· .'i) :.lcm l' IU LH "\" \ OT I C'IL • • • • 1"11is llu l k i: is uut a p plica l,lc lu ,l c1ai11c:cs 111ulc1· 1 hc a :; c of 18. • • • • l • S hnn" ?' :II Mn :11111 ,:11.1.:im, En lor.c .: m c n\ ( ll'E l " i ll iu-:luJc hmu wJ p,a�on.11 infumi:i1 iun .1hu1,1 yuu !II Jh.: ( l11lm� i -1 .i�iu.:.: I u�:ll,u :') ) , 1i:111, J puhl i�ly ��J, �1i.1hl .: lnicm�! 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E• i1np<>!!41\II< yu£.k...\l_ig� � SH;i f�mj)jHi:;i l.lli...!illi uumbrcs ;iu1; ;,1; I� n>iBll�IPD tn £1 siSlc:m'I li1cali;aJ01 Di >l"l,11ure u f \ our l n lunualio 11 . ln !",m11,1 1iun ahrn,1 _1·,111 in lh.;: l).:1a1n.:.: Lu�.,lur wi ',l Li� ,;hari;:I 11 1 1h an} p.:1,,m 11 h-1 �uud,1�1• .L ><=Jr.:h u,ini: ; u ui .-',. -N,,mh�, .,n.l·ur .:.�.,.:1 ti ,,l \a,1 ,-, ..,.,., , aml , ,uu · �••Llllll) ul \>1 1\h \ ,iur 1111 ,>m1.,11<,11 1,, ill 1 '-' nl4i11 in lhc !kt.line,: l �.;,1l<1r 1-. hil.: 1 ,111 �lc ill ICE � u , 1, ,.\1 .,ud l•l! oll ,l:i, ; .1l\,.;1 } ->Ll .If.: r.:lo.>sa,l !1 ,,.11 ll'E cu, 1,> Re�· tlad611 de 111 l11formati611: S11 infomnci6n Itri compuiida con cu1lqui•r p,:uon• 'luc \lc,·c � cnl,u una blliq11cda cit cl Localiu,:lo, de Dc1cniJ01 utili z.o.n.:lc m . ,uimeru de c,:1ranjc,o (,.\­ NumLcr) o su primtr nomb,c u apcllid.> euclo ) SIi pai1 de 1udmicn10. Su infurmac ilin qucJara en ol ,i,1om .. mic:nl1115 u.ied •• encuenpu.!I dft 60 Jio.< de h•b•r 1iJ;, li�c('lldo {per eualquior rn6n) o 1cmo,1Je de l:>1 fauJ,,,; Lnido> Nul � . 1 1 11l \\ Ull\�11 _-\.:I t \ ' ,-',. \\-.-\ 1, UI 4 jlCLlL1 i llJl UI � I IJll Ul '-' LII II r,1 r,i,urni nu lhJI 1 11JL11cnJ,ng ul J l 'I" "' ..;,I \ . � \\' .\ L'•lll!,rn Ul ' '" lUc,I fo1 l U\ l• \"bai, unks> .\',Ill .:,,11��111 11-111 1\· lh� 1, ·1; .,( ii ..:.-,,· i t , . . u h�, ,. � p: 11,lin,1 ur �iiiuov.:,I ,-_\\\'_\ p-;11 liun ur . tw<111-> 1 lnrT•>l 1 1 \ "j;,\ \",w I\ ill he :i,\;=,I I" , i � •I :i �c11:11:11c fo1111 inJi-::iling wh�1lic, I 011 '""'� ,11 10 ,l,,;.:l,-,11111 ) •'"' i n l um,HLl•1t,• -t!i"n �11.I h,111 ,m:1li \)' .-\ .I Jn,\ lh� tllc!!al hmuig1 J l i ,lll H .: frn m an,[ ILllllli g;all! l{.::si,,,11s,l,1!i 1;· .,�1 ( !"itk II l 11111.:J :jl;11.:� l ',,,!�). �n,I lh.:: l!.,md�ml s�.;11,il! _-\d tP.I Hl7-296). 2020-ICLl-00006 681 Nutn: ll,j .:, la Ley federal {B \J.S.C. 1 ] 6 7[4){2 ) ) (blH). ICE 110 pu�Jc ,c,· cl•� infonnaci6n 1 d•dunad11 a un indi,iduo 'I"" Lien� una rnlicin:d ponJiclll: c opr"b�J• p><·• L.oJ,cfici"• Laj<> c l nc(a J c ,·io!cncia conln 1 11 mujcrc• {VA\\'.'\), o ,,na 1olj�iru.:i ptndicmc o opr�L..Ja de c·in 1 1 p o T (pan, , ic1imos d: mince i,umano) o uno de ,-iu 1ipc \J, (pa<• .. i�1imu de al1unos dc:h1n,) ,in l,nbc1 rccibiJo d con1en1 imicl\lo dcl indi\'id"c p,1,,a I• ,e ,·c\a.:i6n ?01 .-on enuari al Lo;alizad<>1 de Dctenidos nin11,un11 infom11ciii!I sura �i uucd 1icnc un• io!iciro.:l V A \\ A pe11dien1c o ap,obadA o una 5,0\ici1uJ pMa un11 , is11 1ipo T ,:: tipo U, a no scr 'l"c umL1 de su con;c:ntimi.:.nt<>. Pile [a,·qr infilITPd<, §I QQci•I do ICE si u >1cJ lital rP L. l 07-�96\. Notice and Order of Expedited Removal U.S. Department of Homeland Security DETERMINATION OF INADMJSSIBILITY Event No: �""-(b-'-'-)(7-'-'l('-'E)_____, File No: Date: A206 us 141 January 24, 2014 IntheMattero( JEIFRI ALEXANDER HERNANDEZ-RODRIGUEZ AKA: HERNANDEZ, JEFREN Pursuant to section 235(b)(l) of the Immigration and Nationality Act (Act), (8 U.S.C. 1225(b)(l)), the Department of Homeland Security has determined that you are inadmissible to the United States under section(s) 212(a) (6)(C)(i); D (6)(C)(ii); IE] (7)(A)(i)(J); D (7)(A)(i)(II); D (7)(B)(i)(l); and/or D (7)(B)(i)(II) of the Act, as amended, and therefore are subject to removal, in that: □ 1. You are an immigrant not in possession of a valid unexpired immigrant visa, reentry permit, border crossing card, or other valid entry document required by the Immigration and Nationality Act; To wit: you were apprehended within 100 air miles of the international boundary of the United States of America and Mexico within 14 days of having illegally entered the U.S. by crossing the Rio Grande River in the Southern District of Texas. You illegally entered with the inte.nt to reside and seek employment in the United States. You were not inspected or admitted by an Immigration Officer at a port of entry designated by the Attorney General. l(b)(6); (b)(?)(C) 7(b)(6); {b\(7)/C\ Border Patrol Agent I Signature of immigration officer Name and title of immigration officer (Print) ORDER OF REMOVAL UNDER SECTION 235(b)(l) OF THE ACT Based upon the determination set forth above and evidence presented during inspection or examination pursuant to section 235 of the Act, and by the authority contained in section 235(b)(l) of the Act, you are found to be inadmissible as charged and ordered removed from the United States. l(b)(6); (b)(?)(C) l(b)(6); (b)(?)(C) Border Patrol Agent L Signature ofimmi�o1 (b)(6); Name and title of immigration officer (Print) (b)(?)(C) l(b)(6); (b)(?)(C) ACTING PATROL AGENT IN CHARGE Signature of supervisor, if a\/ll1lable Name and title of supervisor (Print) D Check here if supervisory concurrence was obtained by telephone or other means (no supervisor on duty). CERTIFICATE OF SERVICE I personally served the original of this notice upon the above-named person on (b)(6); (b)(?)(C) ---�J§-�_i_W'l_ -i_____ 1 (Date) Signature of immigration officer 2020-ICLl-00006 682 Form 1-860 (Rev.08/01/07) � Record of Sworn Sta1...,ment in Proceedings under Section 235(b)(l) of the Act U.S. Drpartmcnl or llomclaod Security FileNo:A206 418 141 Event No ii-rb ....l.... CZ.... }IF._.)____. ----------------------­ Officc:LAR.BDO SOOTH, TX, BORDER PATROL STATION Statcmenl by: --=-===-----===== ==== AXA: HERNANDEZ, JBFRKN In the case of: JBIFRI ALBXANDBR HBRHANDBZ -RODRIGtJBZ Date ofBirth: 02/13/1985 Gender (circle one): @Female AtL,iUUmO S01JTH. TX. BORDER PATROL STATJ:ON Before](b)(6); (b)(?)(C) Jn the SPANISH Datc:January 24, 2014 Border Patrol Agent (Name 111d t'llll:) language. Interpreter _NO_NB __ u_sBD ________;Employed by_________ I am an officer of the United States Department of Homeland Security. I am authorized to administer the immigration law.. and to lalc:e sworn statemerns. I want to take your sworn statement regarding your application for admission to !he United States. Before I take your statement, I also want to explain your richLs. and the purpose and consequences of this interview. You do not appear to be admissible or to have the required legal papm authorizing your admission to the United States. This may result in your being denied admission and immediately returned to your home COW'ltry without a hearing. If a decision is made to refuse your admission into the United SIIJes, you may be immediately removed from this COW'ltry, and if so, you may be baned from reentry for a period of S years or longer. This may be your only opportunity to present infonnation to me and the Department of Homeland Security to make a decision. It is very important that you tell me the truth. If you lie or give misinformation, you may be subject to criminaJ or civil penalties. or barred from receiving immigration benefits or n:liefnow or in the future. Except as J will explain to you, you are not entitled 10 a hearing or review. U.S. law provides protmion lo certain perwns who face persecution, harm or lorture upon retwn to their home country. If you fear or have a amcem about being removed from the United States or about being sent home. you should tell me so during this interview because you may not have another chance. You will have the opportunity to speak priva1ely and confidentially lo another officer about your fear or concern. That officer will detennine if you should remain in the United States and not be removed because of that fear. Until a decision is reached in your case, you will remain in the custody of the Department ofHomeland Security. Any statement you make may be used against you in this or any �uent administrative proceeding. Q. Do you understand what I have said to you? A. Yes. Q. You are being processed for Expedited Removal. Has thie been explained to you and do you understand? A. Yee. Q. Do you understand the charges against you deported? A. Yes. and that you are being formally Q. Would you like to speak to a consulate officer? A. No • ... (CONTINUED ON I-831) Pagclof_3_ 1-367A (08/0 I /07) 2020-ICLl-00006 683 U.S. Department of Homeland Security Continuation Page for Form Alien's Name JBIFRI ALBXANDBR HERHJ\NDBZ-RODRIGO'BZ File Number A206 418 141 ,- F-\---�, Event No : !lh_\/_7-\/ I867A Date January 24, 2014 Q. Are you willing to answer my questions at this time? A. Yee. Q. Do you swear or affi:rm that all statements you are about to make are t%ue and complete? A. Yee. Q. What is your t:rua and ccmplete name? A. Jaifri A1exander BERNANDBZ-Rodriguaz. Q. Have you ever used any other names? A. No. Q. When and where were you born? A. I was born on the 13th of February, 1985, in San Juan Del Rio, Quarataro, Mexico. Q. What country are you a citizen of? A. Mexico. Q. What country are your parents a citizen of? A. Mexico. Q. Do you have any family residing in the tJnited States? A. Yes, I have brothere but I don't know where they live. Q. Are you in possession of any immigration documents that allow you to enter or remain in the United States legally? A. No. Q. Do you have any petitione filed on your behalf? A. No. Q. Bow, when and where did you enter the United Statee? A. I crossed the river (Rio Grande River) Thureday (1/23/2014) near Nuevo Laredo, Maxi.co. Q. Were you inspected by an immigration officer at a Port of BD.try? A. No. Q. For what purpose did you come to the United States? A. To live and work in Dallas, Texas. Q. For what length of time did you plan to stay in the United States? A. Per three years and then return to Mexico. Q. Bad you entered the United States illegally just before you ware arrested? A. Yes. x::::rel:i lie� dc-_s 1- - -------�(b)(6); (b)(7)(C) S ignatwe 3 2 ___ of___ Pages Fonn 1-831 O>ntinuation Page (Rev. 08/01/07) 2020-ICLl-00006 684 U.S. Department of Homeland Security Continuation Page for Form Alien's Name JEIFRI ALKXANDBR mmNANDBZ-RODRIGUBZ File Number A206 UB 141 ------No 1l(b)(7)(E) I867A Date January 24, 2014 Bvent Q. Have you aver been appreAended :t,y any law enforcement officers in the tJ'nitaci States? A. Yes. I Q. How many times have you been apprehended by the united Stataa Border Patrol for entering the United states illegally? A. This is my third time. Q. Have you ever been ordered removed? A. Ho. Q. Have you aver lived in the united States before? A. Yes. Q. Would you be harmed or face persecution if you are returned to your native country? A. No. Q. Do you have any questions at this time? A. No. Signature (b)(6); (b)(7)(C) rI'itle Border Pal:rol Agmi.t __3_ of__3_ Pages Fonn I-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 685 Jurat for Record..__ Sworn Statement in Proceedings under Section 235(b)(l) of the Act U.S. Dcpartmtnt orUomdand Security Q: Why did you leave your home counby or oounby of last nzidence? A.TO LIVE AND WORK :IN THE UNITED STATES. Q. Do you have any fear or concern about being retwned to your home country or being removed from the United States? ANO. Q. Would you be banned if you are returned to your home oounby or oounby orlim residence? ANO. Q. Do you have any question or is there anything else you wouJd like to add? A.NO. I have read (or have had read to me) this statement, consisting of --=.__pages (including this page). I state that my answers are true and co� to the best ofmy knowledge and that this statement is a full, true and co""' record of my intenogation on the date indicaled by the above named officer of the Department of Homeland Security. I have initialed each page of this statement (and the corrections noted on page(s)._____, Signature: JBIPRI ALBXAHDBR RBRNANDEZ-RODRIGUEZ AXA: BBRNlWDBZ, Jlll:FRBN Sworn and subscribed to before me at LAREDO SOUTH, TX, BORDER PATROL STATION onJanuary 24, 2014 l(b)(6); (b)(?)(C) (b)(6); (b)(?)(C) Border Patrol Agent (b)(6); (b)(?)(C) Sipalun: of !=mignrica Offiocr BPA Witne55Cd by:----t Page 2. of_1_ J...1167B (D11111 uV1) 2020-ICLl-00006 686 Name: Alias(s): Event#: All: DOB: COB: HERNANDEZ-RODRIGUEZ, JEIFRI ALEXANDER JEFREN HERNANDEZ Name: Alias(s): l(b)(?)(E) Event#: 206418141 All: 02/13/1985 DOB: MEXICO COB: HERNANDEZ-RODRJGUEZ, JEIFRl ALEXANDER JEFREN HERNANDEZ kb)(?)(E) 206418141 02/13/1985 MEXICO Disposition: Expedited Removal (1-860) Disposition: Expedited Removal (I-860) Name: Name: Alias(s): Event#: All: DOB: COB: HERNANDEZ-RODRJGUEZ, JEIFRJ ALEXANDER JEFREN HERNANDEZ tb)(?)(E) 206418141 Alias(s): JEFREN HERNANDEZ Event#: kb)(?)(E) NI: DOB: 02/13/1985 COB: MEXICO HERNANDEZ-RODRIGUEZ, JEIFRI ALEXANDER 206418141 02/13/1985 MEXICO Disposition: Expedited Removal (1-860) Disposition: Expedited Removal (1-860) Name: Name: HERNANDEZ-RODRJGUEZ, JEIFRI ALEXANDER HERNANDEZ-RODRIGUEZ, JEIFRJ ALEXANDER Alias(s): JEFREN HERNANDEZ Alias(s): JEFREN HERNANDEZ Event#: l(b)(?)(E) Event#: l(b)(? )(E) All: DOB: COB: 206418141 02/13/1985 MEXICO Disposition: Expedited Removal (1-860) A#: DOB: COB: 206418141 02/13/1985 MEXICO Disposition: Expedited Removal (1-860) 2020-ICLl-00006 687 SIGMA Event: (b)(7)(E) FINS: 17851616 1. FAMILY NAME(� l.£ttas) first Name Middle Name HERNANDEZ RODRIGUEZ, ROY ALEXANDER 2.ftl;Je 33 9.Sex □ Fmiale Iii Male HONDURAS 8.BirthPlace HONDURAS, N/A, HONDURAS 10.os::/WA� 0 Yes Iii No 11. RleNumba' A206 418 141 12 Bcrd 13.0NS 14 Medical Alert D Yes 3. Co..inl!yofOtiz�p 5. Date� May 9, 2018 4.Alias HERNANDEZ, JEFREN RODRIGUEZ HERNANDEZ, JEFFRY 7.Elirthl:8te 02/18/1985 Event No: (b)(7)(E) Iii No 15. TRANSFER DAlE (Explain) ER/CF HONDURAS Date� Yes (&plain) TO FROM 14'A, A B J.. 16. ADMITTED BY: 19. RB.EASED TO: 17. SEARCJ-IED IN BY: 20. RB.EASED BY: 18. DATE ADMITTED: 21. DATE R8.EASED: 24. Remarks: Subject ID : !s �partrnonl of Hamelnnd $0C1.Jrily 1DHSI. U.S. lmmi9,a1,on and Cusloms Enfo,cemenl (ICE). Enforcement and R0ffl� Potential Matches - There aro potential encounter matches. View potenUal matclies. Hernandez, Jeffry 206 418 141 Person ID 1/h 11711 Person Details I Dale of B1rth 09/22/1987 Conlrolling A-Number 206 418 141 Last Name HERNANDEZ Curren: Age 30 Add1uo11al A· Ulllbers F11st Name JEFFRY Counuy of B1rt Middle Name NIA City 01 Birth N/A (COB) MEXICO rtNS 17851616 Country of C111zensh1p (COC) MEXICO Sex M BOP/I/USM N/A Transgender NIA !(b)(?)(E) Marital Status Divorced SSN N/A Religion NIA Aggravated Felon Status 086 859 115 No Aggravated Felony Convictions Person Comments Prior Expedited Removal and Voluntary Return United States Department or Homel�nd Secu11ty (OHS) US lmm,gration and Customs Enforcemen (ICE). Enforcement and Removal Opera hons (ERO) I Release EARM 5 48 l(b_l(7_l(_El___________�2.<+-0""2-lo 1cu-oooos 699 .... 5/10/2018 Page l of 2 EARM View Encounter SumIR' EARM c_u'..':nl A?:':� _CC:B� _r,,i_E�IC_ �'?�� '!l�I� . �':�o.'.' I�; (b )(7)( Sex,.� D_D.,8; !(b)(6); Subject ID (b)(?)(E) Processing Disposilion: Voluntary Return RCA Look-Up -- • • • • • • ••- • Cas-;, # � Ith 11711 I Case Cai;g� ry : [9j Dock;� DAL • Clo;;d· Dock�I Special Class: Time in Custody: NIA Fmal Order of Removal: No Depan I Cleared Status: 9-VR Final Order Date: NIA Witnessed Proceed W,th Removal· NIA Days Final Order in EffecL NIA ! I- [✓ Select Different Case File - _. Current/ Active Alerts I I Deten11on History vJ Criminal Potential Matches - There are polentlal encounter matches. View potential matches. Hernandez, Jeffry 206 418 141 Encounter Details 5 Encounter(s) linked to Person ID: 0 0 0 @ 0 Subject Ref# ID 5 4 (b)(7)(E) 3 2 Number A- 1 206418141 Vh1m1i=1 Ir Last Name I I HERNANDEZ RODRIGUEZ HERNANDEZRODRIGUEZ 1206418141 I HERNANDEZ1RODRIGUEZ 086859115 HERNANDEZ 1 Historical Priority First Name coc HONOU No Priority 02/1811985 05109/2018 JEIFRI MEXIC 02/13/1985 01123/2014 ROY JEIFRI JEFFRY HERNANDEZ- 'YENFRI ,RODRIGUEZ MEXIC No Priority MEXIC No Priority MEXIC - ---- No Priority No Priority DOB 02/13/1985 03107/2014 09/22/1987 04/2512009 07/01/1985 1010612005 Encounter Details All information below may only be edited in EAGLE ----- Event/ Incident Information Event Numberj(b)(?)(E) Event Occurred On. 04/2512009 I Event Type Administrative Criminal Alien 1----�- - Subject Information FINS 17851616 Operaliof f Secure Community Agg Felon No Aggravated Felony Convictions Pnmary c,1,zensh,p MEXICO Eyes BRO Complexion MED Transgender NIA Dale of Brrt11 0912211987 Mantal Salus· Single SSN NIA Juvernle Venf1ed NIA OcctJpat1on NIA j l: Race· W Origin H Age 30 Age at Encounter 21 He1gn1 NIA Weight NIA Speak/Understand English NIA Read/Write English. NIA Pninary Language NIA "'--Kb.;.;.)(7..;..;)(.....;.E)____________;2�0�20�1cL1-oooos 700 l Unlink F /""""" I Unlink Unlink Pnmary Agent l(b)(B); (b)(?)(C) Ro,e I Nickname NIA Sex M II Unlink 8F H1stoncal P1iort1y No Priority Hair BLK living?. Y i(b)(7)(E) ease l Category f Assigned On 0412 s ,2 o 09 __� ,,, ...,. .,., ,,. (6"");._____. Event Superv1sodL>: (b:.,;).:..: Middle Name NIA Maiden. NIA Case Landmark. DALCO - DALLAS COUNTY JAIL Criminal Type. NIA First Name JEFFRY f Site DAL A-Number 086 859 115 Control Name HERNANDEZ Eooo""""d on Ass,gned On· 0412512009 Role Commenl NIA Processmg D,spcsiuon Voluntary Return INS Status Deportable POE LAREDO, TX Ent,y Date 06106/2006 Entry Class PWA Mexico Apprehension Date 2009-04-25 12:00:0©.0 Site DAL Landmark DFODAL • DALLAS COUNTY GENERAL AREA Arrest At/Near Dallas, TX Juvenile Slatus NIA Accilmpanyang Fam,ly Member Rela�on NIA Accompanying Farrnly Member Subject ID NIA Consequence Der,very Sys ern Selection NIA 5/10/2018 EARM View Encounter Sumrp-.y 1-213 Narrative l CRIMINAL HISTORY: (b)(7)(E) Page 2 of 2 Narrative 1 : Created Date: 05/14/2009 09:41 AM CLASS: 1 I 04/25/2009 Dallas Police Department 'charged with Prostitution. DISPOSITION: No Convection, Time served I ·1MMIGRATION HISTORY: :subject previously granted Voluntary Return to Mexico on 09/14/2001. ENCOUNTER: The subject was encountered by Immigration agents on 04/25/2009 at the Dallas County Jail during the routi n e 'pe rformance of CAP duties. The subject was arrested by the Dallas Police Department for the offense of n tl n 8 1 e ��� :o��e ��ij!!:���� �:�::::: 1:ftea��7'te� :��i��: o� ��l�o���!!�1T; placed. On 05/13/2009 the subject was transported to the Dallas Field Office and personally Interviewed, ;fingerprinted, photographed and entered into the l/h\/7\ff\ ,. Checks were also run In j(b)(7)(E) These checks revealed the crimlnal and lmmtgratlon histories above. �=;�:; ir:a'::. :!:��::'!, I ADMISSIBILITY/ REMOVABILITY: :subject stated that he Is a citizen and national of Mexico who IHt entered the United St.ates Illegally on or a.bout 'April 2006 at or near Laredo, Texas. The subject did not present himself for Inspection or admission by an _immigration officer at a prescribed port of entry. The subject does not possess any type of immigration docume nt that would al low h Im to res Ide or work legally in the United States. The subject Is removable under Section 212(a) (G)(A)(I) of the Immigration and Nationality Act, Allens Present Without Being Admitted (EWls). FAMILY TIES/ EQUITIES: None. CONSULAR RIGHTS: The subject has been advised of his right to speak with a consular official from his country and afforded the opportun lty. GANG AFFILIATION: No known gang afflllatlon. HEALTH: The subject states that he is in good health. No known medication. ,1-77#: .PHONE: The subject was al lowed to make one domestic phone, and the cal I was successful, at 0800 on 06/13/2009 to noone. He dialed phone number , and spoke for 3 minutes. DISPOSITION: The subject requested and was granted a Voluntary Return to Mexico based on his history. Ur,led Stales Depar1rnen1 of Homeland Securny (DHSl US. lmm1graticn and Cusloms Enforcement (ICE). Enrorcemenl and Removal OperaLions (ERO) I Release EARM 5 48 l(b_)(7�J(_E)___________..:,,t2{-l,;02,L!.0�1,h,llcL1-00006 701 .... 5/10/2018 -- EARM View Person Details Page 1 of 1 EARM Sex M Person 10 (b )(7)( ;;.;bf ect ID . b 7 I E □ OB 09122/1987 Current Age 30 COB. MEXIC COC· MEXIC □ rocessmg - ,sposrt� Expedlh!d Remo;ai (1'.'sGii)cd Oo�ke, ·ca1ego,y [aF] -ocde1 HOU---ci�; Ca5-� ii lth\{7\{F Case F..al Order of Removal Vos Final Order Date 01/2412014 Tona 1n Custody NIA Depart/ Cleared Sta1us· BExcludod/Rcmoved Proceed Wllh Removal Vos Days F,nal Order ,n Effect 46 I- ✓ Select Different Case File - 00 vi - Current I Active Alerts RCA L;;;k-:.u; .. - - - - •.,. ...... Special Class. Ootontlon History F.O. or Removal lnadmlsslbllity L ] Crlmin•l7 Pctenllal Matches • Thero oro potential encounter matches, View potential matches. Hernandez, Jeffry 206 418 141 Person Details �Person ID lthl/7\IFI Controll,ng A-Number 206 418 141 Date or Birth· 09/2211987 Lasl Name HERNANDEZ Current Age: 30 Addlhon;,I A•Nl1mbers. Middle Name NIA City of Birth: NIA FINS Fust Name JEFFRY Sex M 086 859 115 Country of B1rtt, (COB) MEXICO Country of C111zensh1p iCOC) MEXICO Trnnsgencter NIA 17851616 BOP/I/USM NIA !(b)(7)( E) M,rntal Status Divorced SSN NIA Rehg,on NIA Aggra ated Fe:on Status No Aggravated Felony Convictions Person Comments Prior Expedited Removal and Voluntary Return Un11ed Slates De;:iat ment of llomeland Secunty (OHS), US lmm,gratlon and Customs Enlorcemen (ICE) Enforcement Releas • EARM 5 48 E)'------------___;,..24-10�201-J.LI IC Ll-00006 .,__(b-'-'! )(?--'-')('-' 702 and Removal Operalrons (ERO) I 5/10/2018 Page I of 2 EARM View Encounter Sum�y EARM Poison ID b l(b)(6); (b)(?)(C) Logged In: Se• M DOB: 09/22/1987 Currenl Age"" JO COB: MEXIC COC. MEXIC r - - -- -- -- U :-c1�;od Do�k.;-l - - -- - - - --- II liiiiliillJc;se caiegory.-[8Fi-o,,";,kel:_H_O Fnal Order of Removal Yes Special Class: Time ,n Custody; NIA Fnal Order Dale: 01124/2014 Depa�/ Cleared Slalus 8Procood W,th Removal: Yes Excluded/Removod Days FinaI Order In Effect: 46 lnadmlsslblllly -c ••� J -- Select O,fferenl Case File - [✓ Current/ Active "" .. Subjeci-10: khVZVE\ P-r�ss-1119-oi;�; io�- E x-P�dltod Rc� 0�;1(,:S 60) RCA ·L�kkUP - - .. - ... - - -- .. - - -• -- -- Alerts D eten;;;;;:;siof;J F�R:10••'._I vJ Criminal Potential Mate hos · There are potential encounter matches. Vlow potential matches. Hernandez, Jeffry 206 418 141 Encounter Details 5 Encounter(s) linked to Person ID: J(b)(7)(E) Subject Ref# ID 0 0 @ 0 0 5 (b)(?)(E) A- Number ;206418141 3 206418141 2 066659115 1 coc Historical Priority HONDU No Priority 02/1 B/1985 05/09/2018 ERNANDEZRODRIGUEZ JEIFRI MEXIC No Priority 02/13/1985 03107/2014 HERNANDEZRODRIGUEZ JEIFRI MEXIC No Priority HERNANDEZ JEFFRY MEXIC HERNANDEZRODRIGUEZ YENFRI MEXIC ODRIGUEZ ROY DOB Event Occurred On 01/2312014 I Ev nl Type Administrative Non-Criminal Individual Subject Information Case Category Unlink SF !Unlink 02/13/1985 0112312014 SF Unlink No Priority 09122/1987 04125/2009 9 Unlink No Priority 07/01/1965 Encounter Details All information below may only be edited in EAGLE Event/ Incident Information EvenI Number l(b)(?)(E) Encountered ,Case on Name First Last Name WRNANDEZ 4 ·1 Operation N/A (b)(?)(E) 10106/2005 Unlink Pmnary Agenl NIA Assigned On Site. N/A Event Supervisor l(b)(6); (b)(?)(C) l/mdmark N/A Assigned On: 01/23/2014 Role I Fl S 17851616 H1s1oncal Pno11r1 No Priority Con ro1 Name HERNANDEZ-RODRIGUEZ Ag9 Felon No Aggravated Felony Convictions M•dd!e Name ALEXANDER Ha>r BRO INS Statu� Inadmissible Alien Nickname NIA Cornple ion MED Cntiy Date 01/2312014 Sex M Ong1n NIA App,eI1ens1on Daie· 2014-01-23 17:30:00.0 Manta! Staius Single Age 33 Landmark 29.10 . 29.10 . SLAUGHTERS AREA JL1venrIe Verified NIA HeIghl 62 A-Number 206 418 141 F11st Nal'.c' JEIFRI t,1a1tjr,n NIA L1v111g? NIA Transgender NIA SSN NIA Occupation LABORER Cnm111al l ype NIA P,m,ary c,nens11,p MEXICO Ro!e Commen NIA Processing D,sp.:is1t1on Expedited Removal (1860) POE LAREDO, TX Eyes BRO l:ntry Class· PWA Mexico Race W Site LRS Dale of Birth. 02/1311985 Arrest At/Near LAREDO, TX Age al Encounter 28 J uvemle Status NIA Werght 130 Accompanying Family Member Reiauon N/A Read,Wr,te Enghsh NIA Cortsequer•ce Delivery Sys em Selection SOTA Accompanying Famoly Member Subiecl ID NIA Soea Understand English NIA Primary Language NIA l )(? )( E ) (b ... 21,,1, 0-o1-1,IC�L1-00006 ..:..:....:. ___________....,.2�0 '-'-- -'-'- 703 5/10/2018 Page 2 of 2 EARM View Encounter Sum� ! 1-213 Narrative Narrative Entry Zone: Z9.10 :Apprehension Zone: Z9.10 ZONES: ! ,,. ·--·--·--·--··--·----·-···----·--------------------- -------� 1 : Created Date: 01/24/2014 06:32 AM I ENCOUNTER: A Laredo Sector Border Patrol Agent encountered the above subject in the Doc P's property, In Laredo Texas, Webb County. After a brief Interview, It was determined that the Subject had unlawfully entered into the United States from Mexico and was not at the Ume Inspected or admitted by an lmmigratlon Officer at a port of entry as :designated by the Secretary of Homeland Security. Subject further admitted to being a citizen and national of Honduras with no right to be in or remain In the United States legally. The subject was placed under arrest and advised of their rights. 'CRIMINAL HISTORY: 'see attached record checks. i I _IMMIGRATION HISTORY: !See attached record checks. 'HEALTH SCREENING: :subject claims no illnesses or injuries. ,CONSULAR NOTIFICATION: The Subject's right to communlca� with a Consular Officer of the subject's native country was offered. Subject ;undenstood and declined the right to contact the Consular Officer at this time. Subject does not claim fear If :retu�e�_to their native counmi: of citizenship. _ ----------·----------� Uniled States Depanment or Homeland .5.!curily (OHS). U S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO) I Release EARM 5.48 (b l(7 HE l �l _ _ _ ___________-=2=0=-20=---'--"'c-='-'ufoooo6 704 5/10/2018 Page I of I EARM View Person Details EARM Poroon ID:� Sex: M DOB 09/2211987 Current Age 30 COB: MEXIC COC· MEXIC •• - . D�spo;tlon:·01i,or RCAL.�;k:up Sub1oci l D b 7 E �P�o�;.1,;g· #• /h\(7\/F Case Category (SF] Oockel: HOU ."c1�sod ·o-;,;;., c�.� O Final Order of Removal: Yos nme In Custody: NIA Final Order Dale: 01/2412014 Proceed With Removal· Yes Days Frnal Order in Effect: 46 I�---------� I Select Different Case Frie - I✓ Depart I Cleared Status: BExcluded/Romoved lnodmlsslblllly • - ... --- - - Current/ Active l I Alerts Spocial Class Ootontlon History F.O. of Ro� L V ] Criminal _,,,....., __"-"-_. __J Potcn!lal Matches - There are potontlal encounter matches. View potential matches. Hernandez, Jeffry 206 418141 Person Details Porson ID 1th \/7\/ I Date of Birth 09/22/1987 Controlling A-NlllTibcr 206 418 141 Current Age 30 Add,t,onal A-N11mbers, First Name JEFFRY Country or Birth (COB) MEXICO 086 859 115 Middle Name NIA City of Bir1h N/A FINS l�st Name HERNANDEZ 17851616 Ccun ry or C1trzensh1p (COC) MEXICO Tr:msgerder NIA Mm,tal Stat(JS Divorced Rel, ,on N/A BOP#rUSM NIA kb\/7}/F) SSN NIA AggrMated Felon Status No Aggravatod Felony Convictions Person Comments Prior Expedited Removal and Voluntary Return United States Depa11ment or Homeland Secu11ty (OHS). US lmm,grat,on and Customs Enforcement (ICE). Entorcemem and Removal Operations (ERO) I Release EARM 5.48 ,.,_bl( ....., )(7'-'-')(=E)'--_____________.:.2�0 "-ll' 2dl-lCLl-00006 705 5/10/2018 EARM View Encounter um!J)Q,(y Page I of 2 EARM Person ID.™ Sex· M DOB: 09122/1987 Current Age: 30 COB: MEXIC COC: MEXIC Subject ID �!/h\/7\/F\ rP,;coss,n� Dls-�;,,io-;, oit..,- RCA i. o �k-Up .. . - . - - •• Caso #. c.;;, "c-;.teg ory· (8� Docket: HOU - Clo;;d o·ockot Time ,n C..,stody: N/A Special Class: Final Order of Removal Yes F,nal Order Date: 0112412014 Depart/ Cleared Status· 8· Proceed IMth Remo•aL Yes Excluded/Removed Inadmissibility Days Fonal Order in Eflecl. 46 Current I Active Alerts r lllifilill I- I✓ Select Different Case File - v Detention History I F.0. of Removal Criminal Potential Matches - Thero ore potonllal encounter matches. View potontinl matches. Hernandez, Jeffry 206 418 141 Encounter Details 5 Encounter(s) linked to Person Subject Ref# ID 0 @ 0 0 0 (b)(?)(E) 5 A- Number ID:-l(b)(?)(E) Historical Encountered on First Name coc ROY HONDU No Pnorrty 02/18/1985 0510912018 JEIFRI MEXIC No Priority 02113/1985 0310712014 HERNANDEZRODRIGUEZ JEIFRI MEXIC No Priority 02/13/1985 01/23/2014 JEFFRY MEXIC No Priority I 09/22/1967 04/25/2009 HERNANDEZRODRIGUEZ YENFRI MEXIC No Priority Last Name HERNANDEZ RODRIGUEZ 4 206418141 3 206416141 2 086859115 HERNANDEZ HERNANDEZRODRIGUEZ Priority DOB 07/01/1985 Case Case� Category __ (b)(?)(E) BF Unlink BF Unlink 9 Unlink Unlink 10/06/2005 Unlink 7 Encounter Details All information below may only be edited in EAGLE Event I Incident Information Event Number !/h\17)/F\ Opera1,on NIA Even Type CAP Federal 1° nmary Agent. !(b)(6); (b)(?)(C) Site. NIA Landmark NIA Ass,gnM On. 031 70 1 20 1 4__ � ,,,, ...,. .,.., ,,. _ Even! Superv,so,l(b)(6); __ Assigned On- 03107/2014 FINS 17851616 H1stoncal Pr,omy No Priority Role P Control Name HERNANDEZ-RODRIGUEZ Agg Felon· No Aggravated Felony Convictions Processing D1spos1t1on Other Middle: Name. ALEXANDER Hair BRO N,c name N/A Comole ,on MED Event Occurred On 03/07/2014 Subject Information A-Number 206 418 141 F,rst Name: JEIFRI Mn den- NIA Living? Y Sf'X M Crnninal Type NIA Primary Citi2ensl1ip MEXICO INS StattJs Inadmissible Allen Eyes BRO Entry Date 0112312014 Race w Ong,n NIA Transgender NIA Dale of Birth 02/1311985 SSN NIA Age at Encounter 29 Occupation LABORER Weight 130 Marilal Sta:us Single Juvenile Ven�ed NIA fsole Comment NIA Age· 33 POE LAREDO, TX Enuy Class PWA Mexico iwprtnenson Oate 2014-03-07 16:40:00.0 Ste HPC Lilndmark. FDCHOU • BOP FEDERAL DETENTION CENTER, HOUSTON, TX Arrest AUNear· HOUSTON, TEXAS Height 62 ,Juvcn11e Status: N/A Speak/Understand English NIA Accompanying Family Member Subiect ID NIA Read/Write English NIA Accompanying Family Member Relation NIA Consequence Delivery System Selcct,on NIA Pnmary Language SPANISH =l• :le2l'l:b for twc year, ao.d � moalhs frcin the �le cf the sean,h_ .... . 2020-ICLl-00006 709 _,. .. ... Transaction No. LEAVE BLANK Afis No. LEAVE BLANK (STAPLE HERE) CRIMINAL □ STATE USAGE FF SECOND SUBMISSION APPRO ATE CLASS □ □ SCAR AMPUTATION LAST NJJ.IE FlRST NAME MIDO\.E NAME SUFFIX STATE USAGE HERNANDEZ RODRIGUEZ, ROY ALEXANDER SIGNATURE OF PERSON FINGERPRINTED LEAVE BLANK SOCIA!. SECURITY NO Al.lASEs/MAIO( N LAST NAME. FIRST NAME. MIDDLE NAME. SUFFIX HERNANDEZ, ,/EFFRY HERNI\IIDEZ, JEFREN HERNAl/01!2-R0�R IGUF.2, JE!FR! (b)(?)(E) STATE IDENTlfiCATION NO DATE Of BJRTH ., l DD YY 02/18/1985 2 R.INOEX LEFT FOUR FINGERS TAKEN SiMUTANEOUSl. Y RACE HEIGl!T V-IBGl!T 508 160 M < R RING 3 R!AIOllt.E L lHUMB SEX R THUMB 5 R llTTlE RIGHT FOUR FINGERS TAKEN S JUTANEOUSLY THE IMAGES i\ DIOR DAT/\ CONTAINED I IEREI WERE 013Ti\lNED FROM TIIE LOS i\ GEL ·S COUNTY R.EGION/\L IDENTIFICATION SYSTEM ARCHIVE A DARE RESTRICTED FOR OFFICIAL LI\ W ENFORCEMENT USE ONLY. •• •• OTE u ••Tl-11:.SE IMAGES /\ND DATA /\RE PART OF THE ORIGINAL NIST FILE IN THE LIVESC/\ IDE TIFIC/\TION REQUEST R 'CEIVED BY Li\CRIS. ••••NOTE•• .. 2020-ICLl-00006 710 EYES BRO tWR BRO Transaction No. Afis No. FEDERAL BUREAU OF INVESTIGATION, UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 J'RIVACY ACT OF 1974 REQUIRES THAT FEDERAL. STATE OR LOCAL AGENCIES INFORM INDIVIDUALS VoitiaSE SOQAL SECURITY IS REQUESTH) WHETHER SUCH DISCLOSURE IS w.NDATORY OR VOLUNTAAY, BASIS CF AUTKCRITY FOR SUCH SOLICITATION. ANO USES WHICH Will BE MAOE OF IT .11,NEkllE Fl >IG F '1WIGE..CITA,T- ral\dlng io1ec�o, • Al.ID! INl\ll!(ISSIBILITY l/NllER SF.t'TlON 212 1 l 3. I ACDlllO- AlltllTlONM. AlllllTIONM. IIUC-.0 TIO N Flm CAIJT101j STATE -EAU ST""'P THE IMAGES A ND/OR DAT A CONTAINED HEREIN WERE OBTAINED FROM Tl IE LOS ANGELES COUNTY REGIONAL IDENTIFICATION SYSTEM ARCHIVE AND ARE RESTRICTED FOR OFFICIAL LAW ENFORCEMENT USE ONLY. •• .. NOTP" .. T i tESE [�AGES AND DATA ARE PART OF THE ORIGINAL NIST FILE JN THE LIVESCAN IDENTIFICATION REQUEST RECEIVED BY LACRJS. u• 0 NOTE uu 2020-ICLl-00006 711 [!] ""°TO AYM-"111.E? I I> US GOYl:RNMENT, INDICATE S,oE<:tFIC AGfNCY I> llll.CTAAY, UST BAA/IC� OF SE!MCE jlJ(0 SERIAi. NO STATE YES D LEAVE BLANK CRIMINAL (STAPLE HERE) □ STATE USAGE ST�\TE USAGE FD-249(R v.5-15-I7) □ LEAVE BLANK APP!lOXIM�fE CLASo 1110 0046 HERNANDEZ RODRIGUEZ, ROY ALEXANDER s.,u•��ruqE oi=: PERSO'.i F1'.GEflrr .•• ·ro soc ,\L SECURr:-Y r.o �{f?,1!JP/ll���------'---------� HERNAh'DEZ. HERl!ANDEZ. JEFFRY JE FRE:N HERNI\NDEZ-RODRIGUEZ, UHIVERSA. co•� l ROL •..o l(b}(?}(E} JEIFRI D�TE Qr B ITTH 02/18/1985 RAC[ Sl;X M w ►�EJGtH 508 EYES 160 BRO ►{A.IFI RO FEDERAL BUREAU OF INVESTIGATION, UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION,CLARKSBURG, WV 26306 1m nal )us1ice purpos.os, ::.ud1 os mc1cJcnt to iu1tH,la ancJ � q rnt?mlly tiuthorizcd uncfo1 26 USC 534 Thi'$ FD·249 1s. to be us.e The FBl's acqrnsihon. pr serva1tor1. and exctrnr1y • of 1dun11f1Ct1I c.m 111tcH1 ,Ice purposes. "A Social Secur1lr Accounl N>Jmt,,., (SSAN) lncarccrat1ons The Applicant tom, (FD-2581 conta,ns anpl caolo Papol\'I •(l"cllon Acl and Privacy Act notices arid should be used fa, ncncnm, is holplul to eep, cords nccurato bcc.1uso oth+ r people m,ty h,1vt 1110. •. t1Jm, ,ind b,1111 data. Pursuonl to the rederal Pm•acy AC! or 1974 (5 U- 552a). ,my Feder<1l Stat'. or roca gov�rnmPnt unencv winch requests an ind1v1duat to disclose his/hor SSAN ,s r.:,sponsibl� for ,r,fo,m ng lhQ per ·on whothN d,sciosure is mandatory or votur.rary. bf what slat-.!ory or other authority tho SSAN 1s sol e>lcd, ond [ what uses w1.I be made ot 11. " 1(b}(?}(E} n�TE or Af1Rft., T ORI JUVENILE 'lrES □ □ 05/09/2018 \O.! llll COr< 111,au IOA YY A □ Wtl:.SS "EPlY OfSIREO 0�1 l 01 01 re•. , SE! D CO'"'t TO IErJTER OR '·" .� AR-206418141 VES D SAN YSIDRO.CA fll .\l'�E OF BIRTH l5TA.TE OR cou�"':'"RV HONDURAS 05/09/2018 it, S, RS ••••h�S TAl!OOS ANO , .. SC[lLA�,Eaus. iUMflf.qs ICE ENFg�22�;1r ,1D REMOVAL OPERATIONS 880 FRONT s�.fltieiIDRO.NOfrEGO, CA us 92101 t.. JUr-.it�v )I Cllt.![•�S 11P HONDURAS ,.._,.,-UTAiTIO�tS STAil! R s,or·.cr,,.:a•.. P,L1L A00f1ESS OFFICIAL TA.KING F ',GERPRl•ITS (HAME 011 JJUtlBEFI r }(6); (b)(?}(C) EMPLUHH I ,o �l D � .. 11Fl'"'Ar1ori nEt'"F"qE'• l(b}(?}(E} I E It- U '.:> liU\/t.tHIMl:.fl l l�lDICAT[ SP[Clrtt! ACirNCY If- MILll'AfiV USl Br!M!CH or StJWICE IVJL) SEftlAL NO OCCUPATION CHARGE/CITATION 201B0509 • ALIEN INAflMISSIBILITY UNDER SECTION 212 DlSPOSITIO\, , Pending 2 2 � 3 AOOITIOt AL A.001nor�AL ADDI! OIML l',ro11�•,110•, BASIS fOI< CAUTIO·. c;fATE. BUREAU Sl;;•.1p E:] .,,. U.S. GOVERIIMEIIT PUBLISHIIIG or ICE. 0 \ J(J 0 I 8092835 2020-1 C Ll-00006 713 PMOTO AVAll ._Bl[ I YES p:,L�+ PRl',TS TA Efl1 YES Lxl □ LEAVE BLANK CRIMINAL (STAPLE HERE) F0-2�9 (Rev. S-IS-17) 1110-0046 □ □ STATE USAGE LEAVE BLANK SCAR SLJBMISS 0� LAST 1-tAMF , !HST NAME'., MIDOL[ NAVlit $\JF=FIX HERNANDEZ RODRIGUEZ, ROY ALEXANDER s ,_ ,..•AL SCCURIT •�, HEIWAIICEZ, JEFFRY HEIUIAIIOEZ, JEF"RE!, HERNAllOSZ-RODRIGt/EZ, JEIFRI llNIVcRSAl COrHROl NO (b)(?)(E) STAT[ IOENTlflCATIO'I NO DATE OF BIRTH rl'M 02/18/1985 DD YY SD M l!EIG>ff 508 WEIGtH 160 EYES BRO HArR RO FEDERAL BUREAU OF INVESTIGATION, UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTll";E INFORMATION SERVICES DIVISION.CLARKSBURG, WV 26306 The FBrs acquis. tr0n. preservaho.n Md exchange ol I(!, ..,,.•�ton 111!ur m n.al ,ustl-C purpo-ses. such as- 1r-odun1 o a,rests and s ggoe,,1 ,• authori,ed ur.de• 28 USC 53-l This FD·2�9 s 10 ,, u nca,wral10ns "The Appt�.1 fo,m tFD-2581 coma,ns app c:ufr Paper, iduct10n ,'\C a� Pr ac:y Act notie:es nnd houln be used foe none.rim ,'. Cl) pUlpo •$ ,, Soc,al Secu·•:r 1\ccoim1 t:umoer l, ts r.1p.ul lo ,t•,:-p rea:irds acQ.Ir.J1n b9cou:.o omcr peopr� m.oy h..1ve ltle s..:a.. � name and b1ttt1 Uale Pursuant IJ ttR F r1 tal Pr vacy� or 197■1 !5 U 5:52al. an, Fud,,1111 State. O' loca go��rr.men: ���ncy \',hiCM requ�sls ,m '"°·Vldual to di-sdoso h:falhC'r SSAN ,is respon�1bla for m1ormmg me parson wt,othl.!r 0IScios.ure is mora:�10rv or vo'untary. by �"'h;1l jr;latutory or 01har .:1u:hor1ty 1he SSA ' is so11c1tcd, and what uses w 11 bt! made 0111 . k l(b)(7)(E) JUVE NH I f ltlCl UHM�C►t OF S�R\/tCC A'., SF.RIAL NO occur 1 11.r10N Cl-IA or C TA{ION 20180509 - !,LIEN WADMlSSIDlLlTY UNDER SECTION 212 DIS� I IOf,1 t Pending 2 3 :J AOOIT 10',Al A�Jo1• o•.;.l ADOITIONAl INFORMATION 6,\SI� I OR CAUTlat, ' ATE nunEAU STAMP �- IEw U.S GOVERNMENT PUBl•SHING OFFICE: 011197018 0 28 35 2020-1 C Ll-00006 715 STATE PIIOTO AVAILABLE' fES PA!J,I �Alrns lAHta• VES Q □ LEAVE BLANK CRIMINAL (STAPLE HERE) □ ST/ITE USAGE STAl[ USAGEc F0-249 (At>V. 5-15-17) 1110·0046 HERNANDEZ RODRIGUEZ, ROY ALEXANDER SOCIAi SECUi:IITY t-.0 �ION,\IURE OF r! ilSON f:NOlRP1111ITED ,.1,u,4 ;ESIMAIDf.!, LA.' t •,A,•.4E �!R □ LEAVE BLANK '•A �E '·' .... f LEAVE BLA�o< •,,;,,1;:: ti f, HERllhl ;duc11on Act and l'rivacy Act not,cos and shmil,1 be usea lo, noncr,m1. ,1,ce purposes. "A Soc,al Securuy Acroun< Numhor iSSAr-J) 1s h1•I lul to e ? recmds accurate oocaus,• o:her Jl'!OP'" may have 11\o s;,, .. ., namo �nd b!rtn d.11u Pursun,H 10 the Federul Privacy Ml al 1974 15 l,,-u 552a) any Federol Sl�le or local g(ivernmenl uqcncy wt1ich roqueste ao ,no·vldual to d1sc.loso h:s.:'her SSAN tS rl!spcnc!�8 tor ntorm '9 the p('I� ,or, \.\hCth!:!r chsc osurn 1s mand;1:tory a, olur.! e,y ty wMI sto111:o,y or othe; authority ho SSA ,s so1 ci!ed. ard t\:-US, US'!S .-�1 b4r miide ol 1t JUI/PULE Flr-�O nrRlflT VES SURMl$SI0r, rn1 ,\r ,\S AOUU S[r,o COP IEIHER ORI! YE, □ □ OATE OF ARWST v·, .,,, 05/09/2018 DO 1(b)(?)(E) ORI COrJTRIUUTOR ,ooRt < RULY ·re o� on TO DE91REC'' MM Mir.CElLMJEOU5 IIUMDER 1l:1'AS \1.nK, DO 05/09/2018 TA HOOS �NO AMF 1 11t,UIO □ FRONT YES � X :... �"'r ain HONDURAS n I i{blf7l/El ICE ENI,� P -',Cl; OF n ;,---. �� SE I r 0 4tfAN • OVAL OPERATIONS 880 DIEGO, CA us 92101 '• n,· cotJ•., J Y OF C 1,; �.srl P HONDURAS s AR-206418141 or I IGIAL T,\t<;ltff, FrNGEnPAlrHS I 1\',K on NUMUUlt _] (b)(6); (b)(?)(C) [MfJl,(j t I AESIDENCE·COMFl EH ADDRESS C •y LOCAL IDENT IF ICAtlONdH F'EHfNCE PHOTO Al/All.ADLE 1 YES PJ.1.',' P� •,-;5 TA.r.(N YES l=$50 < $500 OFFENSE CITATION PC 31. 03 (e) (2) (AI) OFFENSE DESC M0666423 2020-ICLl-00006 733 � � LEVEL & DEGREE DISPOSITION DISPOSITION DATE REFERRED MISDEMEANOR - CLASS B HELD 04-08-2006 TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS PROSECUTION DATA PROSECUTION AGENCY TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE ******************** TEXT OF MESSAGE ************ ** ** PAGE 05 *************** DALLAS PROSECUTOR ACCEPTS THE CHARGE ACTION THEFT PROP>=$50 < $500 OFFENSE PC 31. 03 ( e ) ( 2 ) ( AI ) CITATION M-0666423 OFFENSE DESC MISDEMEANOR - CLASS B LEVEL & DEGREE COURT DATA TX057303J - COUNTY CRIMINAL COURT NO 5 DALLAS COURT AGENCY THEFT PROP>=$50 < $500 COURT OFFENSE CITATION PC 31 . 0 3 ( e ) ( 2 ) ( AI ) MISDEMEANOR - CLASS B LEVEL & DEGREE DISPOSITION CONVICTED 04-20-2006 DISPOSITION DATE SENTENCE DATE 04-20-2006 ******************** TEXT OF MESSAGE **************** PAGE 06 *************** CAUSE NUMBER M-0666423 NO CONTEST OR NOLO CONTENDERE FINAL PLEADING CONFINEMENT 30D 800 FINE COURT COST 249 TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY ======================================================================--------EVENT CYCLE 2 TRACKING NUMBER ARREST DATE TYPE AGENCY NAME 1(b)(7)(E) I 07-11-2008 ADULT TXDPDOOO0 - DALLAS POLICE DEPARTMENT HERNANDEZ,JEFREN RODRIGUEZ TRACKING SUFFIX AOOl ******************** TEXT OF MESSAGE **************** OFFENSE DATA AGENCY ID NUMBER AGENCY CASE NUMBER OFFENSE AGENCY OFFENSE DATE OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE DISPOSITION DISPOSITION DATE REFERRED 1024266 l(b)(7)(E) PAGE 07 ************** * I TXDPDO0OO - DALLAS POLICE DEPARTMENT 07-11-2008 PROSTITUTION PC 43.02(a) M0860167 MISDEMEANOR - CLASS B HELD 07-11-2008 TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS ******************** TEXT OF MESSAGE **************** PAGE 08 *************** PROSECUTION DATA PROSECUTION AGENCY TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS 2020-ICLl-00006 734 � PROSECUTOR ACCEPTS THE CHARGE PROSTITUTION PC 43.02(a) M-0860167 MISDEMEANOR - CLASS B ACTION OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE COURT DATA TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS COURT AGENCY PROSTITUTION COURT OFFENSE PC 43.02(a) CITATION MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION ******************** TEXT OF MESSAGE **************** PAGE 09 *************** 05-12-2009 DISPOSITION DATE 05-12-2009 SENTENCE DATE M-0860167 CAUSE NUMBER NO CONTEST OR NOLO CONTENDERE FINAL PLEADING 45D CONFINEMENT FINE 400 COURT COST 313 TX0570000 - DALLAS COUNTY SHERIFF 1 S OFFICE RECEIVING CUSTODY --------------================================================================= EVENT CYCLE 3 !(b)(?)(E) TRACKING NUMBER ARREST DATE 04-25-2009 TYPE ADULT AGENCY TXDPD0000 - DALLAS POLICE DEPARTMENT NAME HERNANDEZ,JEFFRY ******************** TEXT OF MESSAGE **************** PAGE 10 *************** TRACKING SUFFIX AOOl OFFENSE DATA 1099043 AGENCY ID NUMBER AGENCY CASE NUMBER !(b)(?)(E) I TXDPD0000 - DALLAS POLICE DEPARTMENT OFFENSE AGENCY 04-24-2009 OFFENSE DATE LEWD/IMMORAL/INDECENT CONDUCT OFFENSE ABC 104.01 CITATION OFFENSE DESC M0955596 LEVEL & DEGREE MISDEMEANOR - CLASS UNKNOWN DISPOSITION HELD 04-25-2009 DISPOSITION DATE TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE REFERRED ******************** TEXT OF MESSAGE **************** PAGE 11 *************** DALLAS PROSECUTION DATA PROSECUTION AGENCY ACTION OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE COURT DATA COURT AGENCY COURT OFFENSE CITATION TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS PROSECUTOR HAS CHANGED THE CHARGE LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 M-0955596 MISDEMEANOR - CLASS B TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 2020-ICLl-00006 735 ,-_ ******************** TEXT OF MESSAGE **************** PAGE 12 *************** MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION 05-12-2009 DISPOSITION DATE 05-12-2009 SENTENCE DATE CAUSE NUMBER M-0955596 NO CONTEST OR NOLO CONTENDERE FINAL PLEADING 45D CONFINEMENT FINE 100 253 COURT COST TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY TRACKING SUFFIX A002 NO OFFENSE DATA AVAILABLE ******************** TEXT OF MESSAGE ** ************** NO PROSECUTION DATA AVAILABLE PA GE 13 *************** COURT DATA TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS COURT AGENCY LEWD/IMMORAL/INDECENT CONDUCT COURT OFFENSE ABC 104.0l CITATION MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION 05-12-2009 DISPOSITION DATE 05-12-2009 SENTENCE DATE M-0871060 CAUSE NUMBER NO CONTEST OR NOLD CONTENDERE FINAL PLEADING CONFINEMENT 30D FINE 750 249 COURT COST ******************** TEXT OF MESSAGE **************** PAGE 14 *************** TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY ====================================================================----------- NO CUSTODY DATA AVAILABLE UNAUTHORIZED USE OR DISCLOSURE OF THE INFORMATION CONTAINED IN THIS RECORD MAY RESULT IN SEVERE CRIMINAL PENALTIES. SEE TEXAS GOVERNMENT CODE SECTION 411.085. END OF RECORD CRIME RECORDS SERVICE DPS AUSTIN TX 03/10/2014 * * *END OF RECORD* * * 2020-ICLl-00006 736 15:52 r--. QUEUE NAME: (b)(?)(E) MSG STATUS: ******************** TEXT OF MESSAGE **************** FROM NCIC ON 03/10/14 AT 15:49:12 QUEUE TYPE: 03102 014 TECS II �XTERNAL MESSAGE DISPLAY (b)(?)(E) PERSONAL PAGE 01 *************** THIS NCIC INTERSTATE IDENTIFICATION INDEX RESPONSE IS THE RESULT OF YOUR INQUIRY ON l(b)(?)(E) PUR/ C (b)(?)(E) NAME INQUIRY DATE l HERNANDEZ,JEFREN RODRIGUEZ 2014/03/10 �----� I SEX RACE BIRTH DATE M W 1984/12/24 HEIGHT WEIGHT EYES HAIR PHOTO SOS 110 BRO BLK Y BIRTH PLACE MEXICO PATTERN CLASS FINGERPRINT CLASS ******************** TEXT OF MESSAGE UC UC UC UC UC UC UC UC UC UC UC UC UC UC UC ALIAS NAMES HERNANDEZ,JEFFRY HERNANDEZ-RODRIGUEZ,JEIFRI A **************** UC UC UC UC UC UC UC UC UC UC UC UC UC UC UC PAGE 02 *************** HERNANDEZ,JEFREN HERNANDEZ-RODRIGUEZ,JEIFRI ALE OTHER BIRTH DATES MISC NUMBERS 1987/09/22 AR-206418141 1985/02/13 AR-A206418141 IDENTIFICATION DATA UPDATED 2014/03/07 ******************** TEXT OF MESSAGE **************** PAGE 03 *************** THE CRIMINAL HISTORY RECORD IS MAINTAINED AND AVAILABLE FROM THE FOLLOWING: TEXAS - STATE ID�(b)(7)(E) FBI i(b)(?)(E) THE RECORD($) CAN BE OBTAINED THROUGH THE INTERSTATE IDENTIFICATION INDEX BY USING THE APPROPRIATE NCIC TRANSACTION. END 2020-ICLl-00006 737 031014 rb)(7)(E) 15:44 TECS II - PERSON SUBJECT QUER� TIDd/h\/7\/F\ ! ,___M_I..,.........,A,---_, NAME- LAST HERNANDEZ RODRIGUEZ (?) FIRST JEIFRI INCLUDE NICKNAME SOUNDEX X DATE OF BIRTH- (START) 02131985 (STOP) STC NCIC QUERY Y PASSPORT NBR (?) CNTRY AFN (?) (?) MISC NBR AR-A206418141 AFN RCPT DRIVER'S LIC (?) STATE CNTRY SSN PILOT 1 S LIC (?) CNTRY ATF PROFILE (?) CRIMINAL AFFIL CASE NBR PHONE FINANCIAL ACCOUNT (?) INTL PREFX (? l ALT COMMUNICATION CNTRY OTTS TYPE ADDRESS- STATE LIMIT RESULTS BY RACE W SEX M CTZN 1 1 NON-SUSPECTS ALSO QOERY (ENTER X TO SELECT AND STATE ID AS INDICATED) CTTP N NLETS-STATE(S) X ARCHIVED RECS X CROSSINGS X SCNDRY INSP X INCIDENT LOGS FINANCIALSCTR FBA LIMIT TO AGENCY/SUB-AGENCY (ASA) NO MATCH FOUND. CSN CMIR QUERY RCN TECS RECORD ID (b)(7)(E) 2020-ICLl-00006 738 Subject ID .S. Dcpartmenl of Homeland Securit y f•m1ly Nome (CAPS) HERNANDEZ-RODRIGUEZ, JEIFRI ALEXANDER Counny of Cuizcn1h1p Record of Dcportable/Inadmissible Alien jth\/7\/t=\ Fi Cane Na: (h\(7\(F\ IA206418 Pu.sporl Number and Country of Issue MEXICO Sex M Middle full U.S. Addrc,s Height 62 1-bir BRO Weighl 130 Eye, BRO Cmpbo MED Occupulon LABORER Sc:;,rs aad M11rk$ 15850 EXPORT PLAZA, HOUSTON, TEXAS, 77032 See Narrative (b)(?)(E) Pa..uengtr UO!lrdcd 11 Number, S11«1, Cl1y, Prov1occ (Staie) and Counrey Cif fi:tmlnffl1 Rnidt',ncC" Mclhod of l.ocalionlAppre en<1on CALLE 12 NOVIEMBRE S/N, SAN JUAN DEL RIO, QUERETARO, MEXICO Oa1cof U1nh Date of Ac:.tion Age: 29 02/13/1985 03/07/2014 C11y. l'Jovmcc (State) IUld Country of Binh R [fil SAN JUAN DEL RIO, QUERETARO, MEXICO Social NIV wulng Po,i and NIV Number CFO 511.2 .3 AIINtat Loa11on Codi: HPC/HOO Form : (Type: t.nd o.) Lllkd Nol Llfled 0 By D 1660 SCARBBRRY Secunry Accoun1 N 1mc TRAVBL/SREKlNG StillilS \Vhco Fou� Status 11 Entry PW.A D10: Vua !Jsucd Da1c/How 03/07/2014 See I ·831 SOCUI Secunty Number Mexico Lcog,h ofTiITTC Illegally in U.S. At Entry Cr.immal Record lmmigm1io11 RccorrJ POSITIVE - See Narrative See Narrative Number .cmd Nacionalhy of Minor Chilc�n:n Name, Addtcu, :and N.a.11on.11H1y of SpoLLSe (Maiden Name:, if Apprnprln.tc) Motlicr"s Prcsc:n.1 and Maiden MEXICO ADDRBSS: , SI\N JUI\N DBL BIO, Fiogcrprin1N? &mi:-.1, Nn11on111\i1y, and Address, if Known ATIONALITY: MEXICO ADDRBS9: , SAN ID T)J>" ofEmploymrnt amc and Addr<1> of(l■>IJ(Cwrng A-Number 086 859 115 Last Nam . HERNANDEZ CUtt�llt Age 26 1\CldltIonaI1 -NJ•nbers. rirst Name: JEFFRY Colt11t1y of B•rth (COB) MEXICO 206 418 141 Middle Name. NIA City ,11 Brrth NIA FINS Sex. M 17851616 Colintry or Crli,enshtp (COC)· MEXICO 17851616 Mantal Status N/A 17851616 Rel,91011: N/A BQPl!/I ISM N/A l(b (?}(E} } Aggravaled Felon Status N . Not an Aggravated Felon SSN N/A Person Comments Voluntary Return United Statt•s Department ot Homeland Securily (OHS). U.S. lmmlgrntio; and Customs [ntorcc111c11t (ICE), [nforcement ,ind Remowir Operations {ERO) I Relense 5 4 l(b_ .... }(?_}(_E}____________2_o_J2P-1cu-00006 744 3/7/2014 HERNANDEZ JEFFRY Subject ID:!:_ic Subject ID .·lili:irrili;;l}roccsslng Disposition: Other RCA Look-Up c; ..-, !(b)(7)(E) !Case Category.- BF i)�.... ttclu ."u,,""as.signed Oo.:ket Bool< In Date: 0J/0712014 Book Out Data. NIA Assigned Un'; N/A Type. NIA Detention Location HOU • HOUICOF Assigned Bed. N/A Treat As Juvenile. No Local COde: NIA Attorney No ified. Not Applicablo Detentlon Classifical,on: Low t i-✓i Current I Active (b}(6}; (b}(7}(C} Alerts In Custody Crlm/nal Potential Mntchos - Thero aro potential encounter matches. View potential matchos. Hernandez, Jeffry 086 859 115 Historyoeten\1011 History for JEFFRY HERNANDEZ [FILTER BY ENCOUNTER/ SUBJECT ID FILTER BY CURRENT/ HISTORICAL RECORDS Show Curreni Detention Records (currently in custody) FILTER BY CASE NUMBER Show Hlstoncal Detention Records USM Book In Date A-Number 0310712014 1709 086 859 115 0310712014 1707 086 859 115 0511412009 1700 086 859 115 Book Out Date Subject !Q Release/ Book Out � In Custody (b}(?}(E} HOU - HOUS N FO HOLDROOM 03107/2014 1708 Transferred . HOU 05115/2009 0649 Released • Voluntary depart1.1re Records with the USM indicator signify detainees that ,ire under the custody of the U.S Marshals but are detained by ERO. l(b}(?}(E} 2020-ICLl-00006 747 3/7/2014 Page I of 2 EADM Detenlion Details EADM Person ID ( Sex: M DO_B�2:��!:,8!_��r!ent �g 26 COB MEXIC COC. MEXI� _ Subjea 10 · b 7 E} rocessing Oisposruon; Other RCA Look-Up Caso #. (b }(7}(E Case Ca\eg;,;,,-;F D�;; HOU - Unasslg�od Docket Book Out Date: N/A Booi< In Dato: 0310712014 Assigned Urut. NIA Type: NIA Ootontlon Location· HOU - HOUICDF Assigned Bed NIA Treat As Juvenile. No Local Code: NIA Attorney Notified. Not Appllcablo Detention Ctass,ricallon· Low Logged In: l(b}(6}; (b}(7}(C} 11 Current/ Active Alerts Potonllal Mate hos. There aro potential encounter motchos. View potential marches. [,._/I In Custody Criminal ............J Hernandez, Jeffry 086 859 115 Detention Details [ a,s ,n lh•& Faoh y 1 (Active) I Oa;-� 111 Custoay 1 (Active) Book In/ Out Book Out Book In Release Date / Time: In Custody In The Custody ot ICE / ERO Releasing Officer. NIA Book In Encounter/ Subject ID: !/bl(7l/El Book out Type: NIA Book In Date I Time: 03107/20141709 Transfer to DCO: NIA Searched By (Off.1 ): l(b }(6}; Transfer to Detention Location: NIA Searched By (Off.2): N/A Booked In By: HOU5349B Delivering Office: HOUSTON, TX, DOCKET CONTROL OFFICE Release Reason: NIA Country of Removal: N/A Booked In DCO: HOUSTON, TX, DOCKET CONTROL OFFICE Agency Type: NIA Local Code: N/A Book. Ou t Medical Discharge Planning: Pending BIiiing DCO: HOUSTON, TX, DOCKET CONTROL OFFICE Current Detention Location: HOUSTON CONTRACT DET.FAC. (IHSC) Detention Classification: Low Assigned Unit: NIA Name of Agency: NIA Attorney Notified: Not Applicable Book Out Comment: Assigned Bed: NIA NIA Treat Detainee as a Juvenile? No Mandatory Detention No IHSC Medical Screen·ng: Pending Detainee Photograph Book In Comment Updale PholO N/A Health Condition Observed at Book In Observation Date/ Time: 03/07/2014 1709 Health Condition Obs:,rved at Book In: Detainee claims Good Health Medication at Book In No Medical Comments: WA Notice: This is not c: .Jnsidered an official med/ell/ �crccn/11g only a quick clmck by the der, 1/ion officer. Only JHSC or am,ther medic�/ expert can meko official medical evfl/uatioris of the dotainot1s; soc IHSC Medical Screeninr;. I- Book Out Edit Information Last Update On: N/A Last Update By: N/A L ason F Edit: NIA :. _J Book In Edit Information Last Update On: N/A �:: s�� :�; :;i�N�;A t d ----- Bio Snapshot at Time of Book Out l(b}(7}(E} 2020-ICLl-opooG 748 3/7/2014 Page 2 of2 EADM Detention Details DOB: COC: COB: A-Number. Last Name: Ftrst Name: Middle Name: [_ �-�-- - - -· -· -- Detention History .Y.§M: Bock la □ate A-Nurnber 086 859 115 _ Ol/071201 • 'll!l! - - -j----:-: .Book Out :Date : In Culltody : Release I Book Oul ,!ti;!!_ : DJ/11712 D14 OS6 859 115 , 03/07/2014 ,1708 · Transrerred - HOU , OSI1412009 !� 086859115 : 05115/2009 10649 : Relea� - Vclunlaiy : departure pro�_ United States Dapanrnen: ,f Horne,ar.d Sacuuly (OHS) U S lmm,g �on and Customs Enforcement (ICE). Enforcement and Removal O�raho�s (ERO) I Relea�e 54 .__)( r 7 p _H_E)_____________ 20_2_0_-I_C_L....J1- 0006 749 3/7/2014 Subject ID : l(b)(?)(E) . . Department of Homeland Security F&mily 'amo (CAPS) BE.RNANDEZ-RODRIGUEZ, JEIFRI ALEXANDER Cowrny of Citizc-nJhip Record of Deportable/lnadmissible Alien Finl Middk Sex F' Case No1 A206418 P111�pon Number tnd Country of ls$ur: MEXICO U.S, Addrcs1 15850 EXPORT PLAZA, HOUSTON, TEXAS, 77032 fleiglu R [ID BPC/BOU Form: (Type tnd 'o.) Uftcd O Social Security Accow,1 'tm< 011,Viu wucd Social Smmiy Number 01 uftcd Sl>tUi II Enny PWA Mexico POSITIVE - See Narrative N13mc-, J\ddrc1,1, 1mJ Natlono.lity of Spow.e (Maiden Name, if Appropriole) nitod DalC/Hour Sl>tUi When Found TRAVBL/SBEXING Lrngth or Tim, Llkplly in U.S. At Entry See Narrative Number a.nd Nationality of Minor Childn:n •• Proenl 111nd Molden Names, NationDlity. and Address.. lf Known MEXICO ADDRESS, , SAN JOAN DBL RIO, lm.mtdUue Pos.\Cs.sioo □S 03/07/2014 By Criminal Record lmmlgnulon Rcoon1 None Claimed At/Near Seo I-831 Ith 1/R\· /h 117\/(:\ NIV Wuini; PO:A aod NIV Number •"fonkt Ouc/Propmy ln U.S. Not i.n □ CFO 511.2,3 Looolion Cod< 03/07/2014 SAN JUAN DEL RIO, QUERETARO, MEXICO � �t�:,d □Mmcd Widowct Method or L=rion/Appr,:hcn>ion DoJc or Action City, Pnrnnc:c (S1>«) and Counuy or Birth LABORER (b)(?)(E) Pll5scDgtr Doordcd a1 CALLE 12 NOVIEMBRE S/N, SAN JUAN DEL RIO, QUERETARO, MEXICO Age: 29 130 MED Occupation Weight Sears and Marks Number, S1ra-1, Ciry, Pro ... i.ru::i: (Smte) and Country of Pmnan�ru Rcsid�nc:i:: 02/13/1985 Cmplxn BRO 62 3/4014, !.AR, WlTHOllT INSPECTION 0,1e ofUlnh Eyes BRO See Narrative D,ui::, rl:a.ei::. Tlmc. a.nd M.:tnnC'r of Lut Entry 0 Ha.tr M ATIONALITY: MEXICO ADDRESS, , SAN fiQicrprin,cd? T)'pc ofEmplo�m• Nam, u,d Addn:u 0f(Las1XCunco1) U.S. Emplo)'t1' N1n,Ui'i'c (Outline p:u11cul1rs under which aliu wu loc1tcd/:1pprth('ndcd, Include detail.snot 1bown above regarding time. pliacc and manner clcmcnu which e:n1bll1b 1dminisin1ivc and/or crimin■I \lfol11ion. Indk11c means 10d rou1c oftnvcl 10 in1c,ior.) FIN: 17851616 Hr or last ntry, .ancmprcd catry, or any other cnlry, Right Index fingerprint Left Index fingerprint -an.d OTHER ALIASES 1':NOWN BY: HERNANDEZ , JEFREN SCARS MARICS AND TATTOOS None Vioible - NONE VISIBLE b)(6); (b)(7)(C) ... (CONTINUED ON I-831) Alien hu been 111dvlscd of comornnica1ion privileges Di11rlbu1lon: FILE LEGAL 31i b)(6); b)(?)(C) !/h\/R\· /h\/7\/f:\ DEPORTATION OFFIC (DOlc/lnilials) (Slg;n1111urc- 11 Received: (Subject ud Docunicnis} om w: J b)(6); (b)(7)(C) (Rtpor1 of Interview) oa: _M_a_r_c_h_7_,_2_0_1_4_1_2_,_o_o_AM _________ ,rim,l _..., _......_�_, Disoo,; .-b- )B ( ); b)(?)(C) ;;:;::::;;::;:;;;:;:;;:;:=::;---------- (b)(6); (b)(7)(C) J;:;: Fonn 1-213 (Rev, 08/01107) 2020-ICLl-00006 750 I-213 Continuation Page for Form ________ U.S. Department of Homeland �urlty Alien's Name File Number JBIPll ALBXANDBR HERNANDEZ-RODRIGUEZ j Date A206 418 141 ____ Event No: 1�,(b-)(7-)(-E} (b)(?}(E} I 03 / 07 / 2014 Health Information The subject claims good health. At/Near HO'O'STON, TEXAS Record of Deportable/Bxcludable Alien: •••••••••••••••••••••••••••••ADDBNDtrM 3/07/14••••••••••••••••••• On Jll.lluary 27, 2014, the SulJject waa convicted of 8 'O'SC 1325(a) (1) in 'O'.S. District Court, Southern District of Texas and sentenced to 45 days confinement. (5114- po-00960) S'O'BJBCT wae released frDZll PDC Houston, TX on Karch 7, 2014 into ICE custody. The Subject will be i■aued an I-200 and I-286 to remain in ICE custody pending removal. Subject is Re.movable 'D'nder Section 241(a) (5) to wit 212(a) (9) (Al {ii) of the INA. Subject was advised of ODLS Privacy Notice and a signed copy is in file. Subject was advised of his communication privileges under 8 CPR 236.l(e). Subject made no claim to 'D'S citizenship. NCIC revealed no outstanding wants or warrants. Encounter Cri.m.inal Charges Illegal Bntry (INA SBC.lOl(a) (43) (O), 8'0'SC1325 only). Charge claesification of 3. Charge statue code of c. Charges Convicted. Sentenced for 45 days. Charged on 2014-01-27T00:00:00. Other Identifying Numbers ALIBN-206418141 1- - --------1(b}(6}; (b}(?)(C} S ignature I Title DSPORTATIOll orrxc:a 2 2 ___ of ___ Pages form 1-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 751 Alerts exist for this encour FINS: 17851616 01/22/2014 09:04 PM 99376215 EnforceCivld: 165893954 Encounter Date: Encounter ID: External Svstem ID: EID Subject ID: 348665915 Event Number: (b)(7)(E) Activity Type: Enforcement Actlvltv Reason: Status Code: Alert OHS-APPREHEND Ornanlzatlon: last Name: I HERNANDEZ-RODRIGUEZ First Name: JEIFRI Middle Name: Gender: DOB: M Height: Eve: Race: 02/05/1985 Weight: Hair. Country of Birth: Countries of Citizenship: Aliases: Last Name First Name MlddleName Scars & Marks: Code Description Name ID Numbers: Type Number Documents: Type Number Country Expiratlon Date Issue Date Apprehensions: Method Tvoe RECIO PB Date Location 1.42 miles E of LAR 01/22/2014 09:04 PM Agent (b)(6); (b)(7)(C) I Status PWAM Alerts: Tvoe Valid Until Removed Alien Alert 2019-01-22 Expedited Removal (Routine) Text ReQuestor SYSTEM Expedited Removal with a 5 year ban on re-entry Comments: 2020-ICLl-00006 752 Lenath AE Alerts exist for this encoumt:r. FINS: 17851616 01/23/2014 05:45 AM 25527B5654 Activitllld: CBLRN0160124140543102418712B Encounter Date: Encounter ID: External Svstem ID: EID Sublect ID: Event Number: Activity Type: Enforcement Actlvltv Reason: Status Code: Alert OHS-APPREHEND Oraanlzatlon: Last Name: HERNANDEZ First Namo: JEFREN Middle Name: Gender: DOB: M Height: 62 Eye: 130 Hair: BRO Race: 09/21/1987 Weight: Country of Birth: w BRO Countries of Citizenship: MEX; Aliases: First Name Last Name HERNANDEZ-RODRIGUEZ MlddleName ALE JEiFRI Scars & Marks: Description Name Code ID Numbers: Tvoe Alien ReQlstration # I 120641B141 (b)(7)(E) Number I Documents: Number Type Issue Dale Country Expiration Dale Apprehensions: Method Tvpe Date Location Status Agent Length Alerts: TvnA Valid Until Removed Alien Alert 2019-01-23 Expedited Removal (Routine) Text Reauestor EBl51TT SUBJECT WILL BE PROCESSED FOR EXPEDITED REMOVAL, 5 YEAR BAN. Comments: 2020-ICLl-00006 753 FINS: 17851616 05/13/2009 07:02 AM 78046416 EnforceClvld: 84595523 Encounter Date: Encounter ID: External Svstem ID: EID Subject ID: 279695848 Event Number: h\/7\/F\ Activity Type: Enforcement Actlvltv Reason: Status Code: Recidivist Oroanizatlon: Last Name: OHS-APPREHEND HERNANDEZ First Name: JEFFRY Middle Name: Gender: DOB: M Height: Weioht: Hair: Countrv of Birth: Eve: Race: 09/2111987 Countries of Citizenship: Aliases: Last Name First Name Middle Name Scars & Marks: Name Code Description ID Numbers: Type Number Documents: Type Country Number Issue Date ExplraUon Date Apprehensions: Method Tvoe RECIO Location UNK Date Aaent 05/13/2009 07:02 AM Status UNK Alerts: Type Valid Until Requester Comments: 2020-ICLl-00006 754 Text LenITTh FINS: 17851616 10/05/2005 02:20 PM 43892284 EnforceCivld: 36942635 Encounter Date: Encounter ID: External System ID: EID Subject ID: 46656683 Event Number: �h\(7\/F\ Activity Type: Enforcement Activltv Reason: Status Code: Recidivist OHS-APPREHEND Oraanization: Last Name: HERNANDEZ-RODRIGUEZ First Name: YENFRI Mlddle Name: Gender: DOB: M 06/30/1985 Helaht: Welaht: Eve: Hair: Race: Countrv of Birth: Countries of Citizenship: Aliases: Last Name Middle Name First Name Scars & Marks: Code Description Name ID Numbers: Number Type Documents: Issue Date Country Number Type Expiration Date Apprehensions: Tvoe RECIO PB Method LocaUon .5 miles E of LAR Date 10/05/2005 02:20 PM A<1ent l(b)(6); (b)(?)(C) I PWAM Status AE Lenath Alerts: Type Valid Untll Reguestor Text_ Comments: SUBJECT IS A CROSSDRESSER THAT ENTERED THE UNITED STATES ILLEGALLY NEAR THE TEX/MEX RAILROAD YARDS. SUBJECT CLAIMS TO BE A CITIZEN OF MEXICO. SUBJECT WAS GRANTED A VOLUNTARY RETURN TO MEXICO. 2020-ICLl-00006 755 FINS: No Mug Shot 17851616 04124/2009 09:01 AM 1289163805 TCN: FBl:sscn2009115000008416 Encounter Date: Encounter ID: External System ID: EID Subiect ID: Event Number: Activity Type: Enforcement Activity Reason: CJIS Search of US-VISIT Status Code: Recidivist Oraanizatlon: Last Name: DOJ-FBI HERNANDEZ First Name: JEFFRY Middle Name: Gender: DOB: M Height: 0 Eye: Hair: XXX u Race: 09/21/1987 Weight: Country of Birth: Countries of Citizenship: Aliases: Last Name First Name Middle Name Scars & Marks: Code Name Description ID Numbers: Number Type l(b)(7)(E) Documents: Number Type Issue Date Country Expiration Date Apprehensions: Method Type Location Date Agent Status Alerts: Type Valid Until Reguestor Comments: 2020-ICLl-00006 756 Text Length FINS: 17851616 03/06/2014 04:30 PM 2591770376 EnforceCivld: 166316889 Encounter Date: Encounter ID: External System ID: EID Subject ID: 349082892 Event Number: Activity Type: Enforcement Activity Reason: ICE EAGLE transaction Status Code: Recidivist OHS - ICE - DNR On::ianization: Last Name: I kb)(?)(E) HERNANDEZ-RODRIGUEZ First Name: JEIFRI Middle Name: ALEXANDER Gender: DOB: M Height: 62 Eye: 130 Hair: BRO Race: 02/12/1985 Weight: BRO Country of Birth: w MEX Countries of Citizenship: MEX; Aliases: Last Name First Name HERNANDEZ Middle Name JEFREN Scars & Marks: Code Name Description ID Numbers: Tvoe Alien Reoistration # (b)(?)(E) I 1206418141 -- Number I Documents: Number Type Issue Date Country Expiration Date Apprehensions: Method Type RECIO Location CFO Date 03/06/2014 11:00 PM Aaent (b)(6); (b)(?)(C) I Status PWAM Lel\alh AE Alerts: Type Valia Until Requester Comments: Comment text may be incomplete. Refer to Event ID#l(bl/7)/E) 3/07/14 •-·········-····· Text J for details ............... ,,,,"'"'• 0•1111•••"'0 .. "ADDENDUM On January 27, 2014, the Subject was convicted of 8 USC 1325(a)(1) in U.S. District Court, Southern District of Texas and sentenced to 45 days confinement. (5:14- po-00960) SUBJECT was released from FDC Houston. TX on March 7, 2014 into ICE custody. The Subject will be issued an 1-200 and 1-286 to remain in ICE custody pending removal. Subject is Removable Under Section 241 (a)(5) to wit 212(a)(9)(A)(ii) of the INA. 2020-ICLl-00006 757 Subject was advised of OOlS PT1vac:y Nol/al erid a Blgn8d oopy la In Ille. Swlec:t was advised of his communlcaUon privileges under B CFR 236.1 (e). Subjeci made no claim to US dllzenshlp. aJed no cu\slandlng wants Of warrants. 2020-ICLl-00006 758 Case 5:14-po-0096,�Document 1 Filed in TXSD on 0lA"?/14 Page 1 of 1 AO91 (Rev. 8/01) Criminal Complaint UNITED STATES DISTRICT COURT SOUTHERN TEXAS DISTRICT OF CRIMINAL COMPLAINT UNITED STATES OF AMERICA V. Jeifrl Alexander HERNANDEZ-Rodriguez Case Number: L-14-P00960 (Name and Address ofDdcndant) I, the undersigned complainant state that the following is true and correct to the best of my knowledge and belief. On or about January 23, 2014 in County, in Webb the Southern District of Texas Jeifri Aleunder HERNANDEZ-Rodriguez defendant(s), an alien, did unlawfully enter and attempt to enter the United States at a place other than designated by immigration officer in violation ofTitle(s) I further state that I am a(n) s United States Code, Section(s) Border Patrol Agent 1325Ca}Ol and that this complaint is based on the following facts: Based on statem cn ts of the accused and records of the U.S. Department of Homeland Security. Furthennore, it is bascd on verbal statements by, Jeifri Alexander HERNANDEZ-Rodriguez, who admitted to being a citizen of Mexico, who entered or attempted to enter illegally into the United States by wading the Rio Grande River near, Laredo, Texas, thus avoiding immigration inspection, nor having proper documents to enter, travel through, or remain in the United States. This illegal entry or attempted entry took place on January 23, 2014 1 Continued on the attached sheet anJ made a pan of this complaint: Yes Signature ofComplainwit Alex Chirinos Print�d Nam,: ofComplailll1llt Sworn to before me and signed in my presence, at January 27. 2014 J. Hacker Name and Title of Judicial Ofliocr Laredo Texas City and Stat,: , U.S. Magistrate Judge S ignaturc of Judicial Olli cer 2020-ICLl-00006 759 ISi Case 5:14-po-0096fal-\Document 3 Filed in TXSD on 0�/14 Page 1 of 2 UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF TEXAS LAREDO DIVISION UNITED STATES OF AMERICA Plaintiff Case No.: 5: 14-po--00960 Magistrate Judge J. Scott Hacker V. Jeifri Alexander Hernandez-Rodriguez Defendant JUDGMENT On 1/27/14, the above named defendant appeared in person and with counsel. Whereupon the defendant entered a plea of guilty to the offense of entering the United States illegally, in violation of 8 U.S.C. § 1325(a)(l), as charged in the Complaint; and the Court having asked the defendant whether he/she had anything to say why judgment should not be pronounced, and no sufficient cause to the contrary being shown or appearing to the Court; IT IS ADJUDGED that the defendant is guilty as charged and convicted. The defendant is hereby sentenced to 45 days confinement, with a special condition not to return to the U.S. illegally or commit any other violation of federal and/or state laws. A $10.00 special assessment is imposed. DONE at Laredo, Texas, on 1/27/14. J/S�bn· HACKER UMITED STATES MAGISTRATE JUDGE 2020-ICLl-00006 760 l(b)(?)(E) COMMAND: DEPARTMENT OF HOMELAND SECURITY - users CENTRAL INDEX SYSTEM - ID# SEARCH/DISPLAY ID# (A/AA/AB/C/DA): A206418141 (DL/FB/FP/I/PP/SS/TD) LAST: HERNANDEZ RODRIGUEZ FIRST: JEIFRI MIDDLE: ALEXANDER ALIASES: SEX: M FCO: SNA PFCO: POE: LAR COA: SFCO: SSN: I-94 ADM#: PASSPORT#: A#: 206418141 03/06/14 23:04:06 DOB: 02131985 NATZ DATE: COURT: LOCATION: COB: MEXIC COC: MEXIC DFO: 01272014 DOE: 01232014 FTI: 03032014 BIN: CONSOLIDATED A-NOS l(b)(?)(E) DRIVER LIC: FINGER CD#: 17851616 (b)(?)(E) 2020-ICLl-00006 761 FATHER: PANFILO MOTHER: MARIA --OTHER INFORMATION-- 12:09 QUEUE TYPE: ,,-,.., TECS II EXTERNAL MESSAGE DISPLAY 03072014 (b)(?)(E) PERSONAL QUEUE NAME : � MSG STATUS: L___J ******************** TEXT OF MESSAGE**************** FROM NCIC ON 03/07/14 AT 12:08:13 PAGE 01 *************** E r)(?)( ) 1 THIS NCIC INTERSTATE IDENTIFICATION INDEX RESPONSE IS THE RESULT OF YOUR INQUIRY ON NAM/HERNANDEZ RODRIGUEZ,JEIFRI SEX/M RAC/U DOB/19850213 PUR/C (b)(?)(E) NAME INQUIRY DATE l HERNANDEZ,JEFREN RODRIGUEZ 2014/03/07 SEX RACE BIRTH DATE M W 1984/12/24 HEIGHT WEIGHT EYES HAIR PHOTO 505 110 BRO BLK Y BIRTH PLACE MEXICO ******************** TEXT OF MESSAGE**************** FINGERPRINT CLASS PATTERN CLASS UP UC UP UP UP UP UC UP UP UP UP UC UP UP UP UP UC UP UP UP UP UC UP UP UP UP UC UP UP UP ALIAS NAMES HERNANDEZ,JEFFRY HERNANDEZ-RODRIGUEZ,JEIFRI A PAGE 02 *************** HERNANDEZ,JEFREN HERNANDEZ-RODRIGUEZ,JEIFRI ALE OTHER BIRTH DATES MISC NUMBERS 1985/02/13 AR-206418141 1987/09/22 AR-A2064l8141 ******************** TEXT OF MESSAGE**************** IDENTIFICATION DATA UPDATED 2014/03/06 PAGE 03 *************** THE CRIMINAL HISTORY RECORD IS MAINTAINED AND AVAILABLE FROM THE FOLLOWING: TEXAS - STATE ID/TX07701800 FBI i(b)(?)(E) I THE RECORD($) CAN BE OBTAINED THROUGH THE INTERSTATE IDENTIFICATION INDEX BY USING THE APPROPRIATE NCIC TRANSACTION. END 2020-ICLl-00006 762 12:11 T�CS II - PERSON SUBJECT QUER� 030714 TID= l(b)(?)(E) I NAME- LAST HERNANDEZ RODRIGUEZ MI A (?) FIRST JEIFRI INCLUDE NICKNAME SOUNDEX DATE OF BIRTH- (START) 02131985 (STOP) STC NCIC QUERY Y PASSPORT NBR (?) CNTRY AFN AFN RCPT (?) MISC NBR (?) DRIVER'S LIC (?) STATE CNTRY SSN (?) CNTRY ATF PROFILE PILOT'S LIC CASE NBR (?) CRIMINAL AFFIL PHONE INTL PREFX FINANCIAL ACCOUNT (?) ALT COMMUNICATION (?) CNTRY LIMIT RESULTS BY RACE SEX CTZN OTTS TYPE ADDRESS- STATE NON-SUSPECTS ALSO QUERY (ENTER 'X' TO SELECT AND STATE ID AS INDICATED) CTTP N NLETS-STATE(S) ARCHIVED RECS CROSSINGS SCNDRY INSP INCIDENT LOGS FINANCIALSFBA CTR LIMIT TO AGENCY/SUB-AGENCY (ASA) NO MATCH FOUND. CSN CMIR QUERY RCN TECS RECORD ID (b)(?)(E) 2020-ICLl-00006 763 � 12:12 TECS II EXTERNAL MESSAGE DISPLAY QUEUE NAME : (b)(7 )(E) MSG STATUS: ******************** TEXT OF MESSAGE **************** FROM NLETS ON 03/07/14 AT 12:11:53 QUEUE TYPE: PERSONAL 03072014 ) )(E) (b � '� - _____. _ _ PAGE 01 *************** kbll7)/fl 10:11 03/07/2014 17680 10:11 03/07/2014 50297 l(b)(7)(E) ( _)(7_ )(_E)__ 1b � � TXT HDR / l{b}(7l/El ATN�(b)(6);�·' ********************** CRIMINAL HISTORY RECORD *********************** 2014-03-07 Data As Of **************************** Introduction **************************** This rap sheet was produced in response to the following request: (b)�)(E) Request Id (b)U)(E) ******************** TE�XUT-=F.---;.;;,;=;;�'11"7"'1� **************** PAGE 02 *************** Purpose Code C Attention �,\!�� \��!'. The information in this rap sheet is subject to the following caveats: This record is based only on the l(b)�)(El I Because additions or deletions may be made at any time, a new copy should be requested when needed for subsequent use. (US; 2014-03-07) All arrest entries contained in this FBI record are based on fingerprint comparisons and pertain to the same individual. (US; 2014-03-07) The use of this record is regulated by law. It is provided for official use only and may be used only for the purpose requested. (US; 2014-03-07) *************************** IDENTIFICATION *************************** Subject Name(s) HERNANDEZ, JEFREN RODRIGUEZ ******************** TEXT OF MESSAGE **************** PAGE 03 *************** HERNANDEZ-RODRIGUEZ, JEIFRI ALE (AKA) HERNANDEZ, JEFREN (AKA) HERNANDEZ, JEFFRY (AKA) HERNANDEZ-RODRIGUEZ, JEIFRI A (AKA) sub'ect Description (b)(7)(E) State Id Number TX07701800 (TX) 0-,�, Miscellaneous Numbers Unknown Alien Registration 206418141 Unknown Alien Registration A206418141 Race Sex White Male Date of Birth Weight Height 5 1 05 11 1984-12-24 110 ******************** TEXT OF MESSAGE **************** PAGE 04 *************** 1984-12-24 1987-09-22 1985-02-13 Fingerprint Pattern Eye Color Hair Color UP UC UP UP UP UP UC UP UP UP ( Brown Black Other) Place of Birth Citizenship 2020-ICLl-00006 764 us MM Fingerprint Images Photo Images E )__ Photo Image Available FBI-CJIS DIV-CLRKSBG CLARKSBURG�l(b�)��)(� � Available Image Other {No Photo Image Transmitted Comment:FBI has two photos associated with arrest date of 2014/01/23) ******************** TEXT OF MESSAGE**************** PAGE 05 *************** E) CBP-WEST BP SECTOR LAREDO 1(b)(7)( Photo Image Available .____ ___. Available Image Other (No Photo Image Transmitted Comment:Arresting agency has photo associated with arrest date of 2014/01/23) FBI-CJIS DIV-CLRKSBG CLARKSBURG WVFBINF00 Photo Image Available Other Available Image (No Photo Image Transmitted Comment:FBI has one photo associated with arrest date of 2014/01/23) ************************** CRIMINAL HISTORY ************************** =============================== cycle 001 ============================== Earliest Event Date 2014-01-23 l 2014-01-23 TEXT OF MESSAGE**************** PAGE 06 *************** (b)�)( E ) Arrest Case Number CBP-LAREDO SOUTH OBP LAREDO Arresting Agency '----�---' HERNANDEZ,JEFREN Subject's Name Charge 01 Charge Literal ENTRY WITHOUT INSPECTION, TIME OR PLACE NOT DESIGNATED � CBP-LAREDO SOUTH OBP LAREDO Agency 1(b)(7)(E) Severity 02 Charge Charge Literal ALIEN INADMISSIBILITY UNDER SECTION 212 CBP-LAREDO SOUTH OBP LAREDO Agency l(b)(?)( E ) Severity Arrest Date I I (cycle 001) Court Disposition Unknown Court Agency Charge 01 ******************** TEXT OF MESSAGE**************** PAGE 07 *************** Charge Literal ILLEGAL ENTRY Severity Disposition (Other; DOCKET #L-14-PO096 45 DAYS 1-27-14) =============================== cycle 002 ============================== Earliest Event Date 2014-01-23 2014-01-23 Arrest Date Arrest Case Number 1(b)(7)( E ) Arresting Agency I CBP-WEST BP SECTOR LAREDO HERNANDEZ-RODRIGUEZ,JEIFRI ALE Subject 1 s Name 01 Charge Charge Literal 0301-ILLEGAL ENTRY I CBP-WEST BP SECTOR LAREDO Agency l(b)(7)( E ) Severity ************************* INDEX OF AGENCIES ************************** ******************** TEXT OF MESSAGE**************** PAGE OB*************** FBI -CJIS DIV- CLRKSBG CLARKSBURG; ICb)(?)( E ) Agency Address 1000 CUSTER HOLLOW RD I; 2020-ICLl-00006 765 � CLARKSBURG, WV 26306 Agency Address _ )()E_ __� CBP-LAREDO SOUTH OBP LAREDO; j�(b)(?_ Agency Address l () ?_)(_E)__� CBP-WEST BP SECTOR LAREDO; �(b_ 9001 SAN DARIO AVE LAREDO, TX 78045 11119 MCPHERSON AVE LAREDO, TX 78045 * * * END OF RECORD* * * 2020-ICLl-00006 766 12:12 r-,., TECS II EXTERNAL MESSAGE DISPLAY QUEUE NAME : (b)(?}(E} MSG STATUS: ******************** TEXT OF MESSAGE**************** FROM NLETS ON 03/07/14 AT 12:11:55 QUEUE TYPE: PERSONAL 03072014 b )(7)(E) r � � - - - -- PAGE 01 *************** !(b)(?)(E) I 10:11 03/07/2014 61058 �1_0: _ _1_1_0_3�0_7 ___.__,2014 50306 1�(b_)(7_}(E_l __� (b)(?}(E) TXT HDR/�(b� )_ (?}_ (E_ }______� ATN/CRUZ THIS RECORD IS BASED ON THE SID NUMBER IN YOUR REQUESTSIDA(b}(?}(E} I TEXAS DEPARTMENT OF PUBLIC SAFETY COMPUTERIZED CRIMINAL HISTORY THE FOLLOWING RECORD PERTAINS TO DPS NUMBER/TX 07701800 NAME(S) HERNANDEZ,JEFREN RODRIGUEZ ******************** TEXT OF MESSAGE**************** PAGE 02 *************** HERNANDEZ,JEFREN(AKA) HERNANDEZ,JEFFRY(AKA) (b}(?)(E} DPS NUMBER TX 07701800 _ _ ID NUMBER DRIVERS LICENSE SOCIAL SECURITY SEX SKIN TONE RACE W LBR M HEIGHT WEIGHT DATE OF BIRTH 12-24-1984 130 502 E PATTERN FINGERPRINT HAIR COLOR YE COLOR BLK BRO PRIMARY CLASS RIDGE COUNT �FINGERPRINT WWWWWLWWWL III CODE PLACE OF BIRTH CITIZEN MULTI-STATE MM US ******************** TEXT OF MESSAGE **************** PAGE 03 *************** ALIAS DOB SCARS, MARKS, AND TATTOOS 09-22-1987 DATE OF LAST UPDATE ORIGINATION DATE DATE OF REPORT 01-24-2014 04-08-2006 03-07-2014 -============================================================-----------------EVENT CYCLE 1 !(b)(?)(E) TRACKING NUMBER I 04-08-2006 ARREST DATE ADULT TYPE TXDPDOOO0 - DALLAS POLICE DEPARTMENT AGENCY HERNANDEZ,JEFREN RODRIGUEZ NAME l I TRACKING SUFFIX AOOl OFFENSE DATA ******************** TEXT OF MESSAGE**************** PAGE 04 *************** AGENCY ID NUMBER 1024266 AGENCY CASE NUMBER !fb}(7l/El I TXDPD00OO - DALLAS POLICE DEPARTMENT OFFENSE AGENCY 04-08-2006 OFFENSE DATE THEFT PROP>=$50 < $500 OFFENSE PC 31.03(e) (2) (AI) CITATION M0666423 OFFENSE DESC 2020-ICLl-00006 767 � LEVEL & DEGREE DISPOSITION DISPOSITION DATE REFERRED MISDEMEANOR - CLASS B HELD 04-08-2006 TX05701SA - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS PROSECUTION DATA PROSECUTION AGENCY TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE ******************** TEXT OF MESSAGE **************** PAGE OS *************** DALLAS ACTION PROSECUTOR ACCEPTS THE CHARGE OFFENSE THEFT PROP>=$5D < $500 CITATION PC 31. 03 (e) (2) (AI) OFFENSE DESC M-0666423 LEVEL & DEGREE MISDEMEANOR - CLASS B COURT DATA COURT AGENCY TX057303J - COUNTY CRIMINAL COURT NO 5 DALLAS THEFT PROP>=$50 < $500 COURT OFFENSE PC 31. 03 (e) (2) (AI) CITATION MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION 04-20-2006 DISPOSITION DATE 04-20-2006 SENTENCE DATE ******************** TEXT OF MESSAGE **************** PAGE 06 *************** M-0666423 CAUSE NUMBER NO CONTEST OR NOLO CONTENDERE FINAL PLEADING CONFINEMENT 30D FINE BOO 249 COURT COST TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY ========================================================---------====�--------EVENT CYCLE 2 lth\17111=1 TRACKING NUMBER 07-11-2008 ARREST DATE ADULT TYPE TXDPD0000 - DALLAS POLICE DEPARTMENT AGENCY HERNANDEZ,JEFREN RODRIGUEZ NAME ------------------------------------------------------------------------- A00l TRACKING SUFFIX ******************** TEXT OF MESSAGE **************** PAGE 07 *************** ------------------------------------------------------------------------OFFENSE DATA AGENCY ID NUMBER AGENCY CASE NUMBER OFFENSE AGENCY OFFENSE DATE OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE DISPOSITION DISPOSITION DATE REFERRED 1024266 !(b)(7)(E) TXDPDOOOO - DALLAS POLICE DEPARTMENT 07-11-2008 PROSTITUTION PC 43.02(a) M0860167 MISDEMEANOR - CLASS B HELD 07-11-2008 TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS ---------------------------------------------------------------------- ******************** TEXT OF MESSAGE **************** PAGE 08 *************** PROSECUTION DATA PROSECUTION AGENCY TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS 2020-ICLl-00006 768 � ACTION OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE PROSECUTOR ACCEPTS THE CHARGE PROSTITUTION PC 43. 02 (a) M-0860167 MISDEMEANOR - CLASS B COURT DATA COURT AGENCY TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS COURT OFFENSE PROSTITUTION CITATION PC 43.02{a) LEVEL & DEGREE MISDEMEANOR - CLASS B DISPOSITION CONVICTED ******************** TEXT OF MESSAGE **************** PAGE 09 *************** DISPOSITION DATE 05-12-2009 05-12-2009 SENTENCE DATE CAUSE NUMBER M-0860167 FINAL PLEADING NO CONTEST OR NOLO CONTENDERE CONFINEMENT 45D FINE 400 COURT COST 313 TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY --------------=----============================================================ EVENT CYCLE 3 !lh \/7\/F\ TRACKING NUMBER ! ARREST DATE 04-25-2009 ADULT TYPE TXDPD00O0 - DALLAS POLICE DEPARTMENT AGENCY HERNANDEZ,JEFFRY NAME ****** ************** TEXT OF MESSAGE **************** PAGE 10 *************** ------------------------------------------------------------------------- A0Ol TRACKING SUFFIX ----------------------------------------------------------------------- OFFENSE DATA 1099043 AGENCY ID NUMBER I AGENCY CASE NUMBER kh\(7\/F\ TXDPD0000 - DALLAS POLICE DEPARTMENT OFFENSE AGENCY 04-24-2009 OFFENSE DATE LEWD/IMMORAL/INDECENT CONDUCT OFFENSE ABC 104.01 CITATION M0955596 OFFENSE DESC MISDEMEANOR - CLASS UNKNOWN LEVEL lie DEGREE HELD DISPOSITION 04-25-2009 DISPOSITION DATE TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE REFERRED ******************** TEXT OF MESSAGE **************** PAGE 11 *************** DALLAS ---------------------------------------------------------------------- PROSECUTION DATA PROSECUTION AGENCY ACTION OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS PROSECUTOR HAS CHANGED THE CHARGE LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 M-0955596 MISDEMEANOR - CLASS B ---------------------------------------------------------------------COURT DATA COURT AGENCY COURT OFFENSE CITATION TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS LEWD/IMMORAL/INDECENT CONDUCT ABC 104.0l 2020-ICLl-00006 769 ******************** TEXT OF MESSAGE **************** PAGE 12 *************** MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION 05-12-2009 DISPOSITION DATE 05-12-2009 SENTENCE DATE M-0955596 CAUSE NUMBER FINAL PLEADING NO CONTEST OR NOLO CONTENDERE 45D CONFINEMENT FINE 100 COURT COST 253 TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY TRACKING SUFFIX A002 NO OFFENSE DATA AVAILABLE ******************** TEXT OF MESSAGE * *************** NO PROSECUTION DATA AVAILABLE PAGE 13 ** ************* COURT DATA TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS COURT AGENCY LEWD/IMMORAL/INDECENT CONDUCT COURT OFFENSE ABC 104. 01 CITATION MISDEMEANOR - CLASS B LEVEL & DEGREE CONVICTED DISPOSITION 05-12-2009 DISPOSITION DATE 05-12-2009 SENTENCE DATE M-0871060 CAUSE NUMBER NO CONTEST OR NOLO CONTENDERE FINAL PLEADING 30D CONFINEMENT 750 FINE 249 COURT COST ******************** TEXT OF MESSAGE **************** PAG E 14 *************** TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY --==----======================================================================- NO CUSTODY DATA AVAILABLE UNAUTHORIZED USE OR DISCLOSURE OF THE INFORMATION CONTAINED IN THIS RECORD MAY RESULT IN SEVERE CRIMINAL PENALTIES. SEE TEXAS GOVERNMENT CODE SECTION 411.085. END OF RECORD CRIME RECORDS SERVICE DPS AUSTIN TX 03/07/2014 * * *END OF RECORD* * * 2020-ICLl-00006 770 MEXICANE/R Aliens Name: ____H_E_R_N_A_N_EZ_-_R..;.. ig""'" le..;.. od.;..r_.. ue , .;..Je'-ifri x.a d...:;.. er____ "-'-n....: -'. .;..A.:..; .:..;z;.:.. 6 ) Processing Agen�L...�b-)(_ )_: (_b _rJ_)(C_)__J_________ Star# J(b)(6); Left Side (Front to Back) , SBPA l(b)(6); (b)(7)(C) A#-: I Apprehending Station: LRS (3 letter code) Right Side (Front to Back) SBPA FOS 1-296 (3 all w/orig Sigs) 1-213 / 1-860 (3 all w/orig Sigs) l dent Alert l-867NB (1X w/orig Sigs} 1-------;i----1 e3 Photo Sheet FOS 1-------l---- / ALL FORP.fS MUST HAVE ORIGINAL SIGNATURES Ill MEXICAN NATIONALS EJR,PREREQUISITES: Recidivist Criminal Alien b)(6); b)(7)(C) SuspeC.!.ed Smuggler/Guide IDENT alert indicates: Criminal, Recidivist, Suspected Guide/Smuggler � t) ' L-\ \ I �vP"> oJ�\){ �l)ll\ Q�� I-{ 0J)\� 1:)-r--\l\II> 5 , 1 ;1.!;NJDl " lNO1 I I I f r b)(6); (b)(7)(C) ..J------ SBPA -------1..._______ FOS ------------------- D Check box. if 2nd Line Supervisor was contacted telephonically 2020-ICLl-00006 771 -me (CAPS) HERNANDEZ-RODRIGUEZ, JBIFRI ALEXANDER Country of Citiuru.hi p MEXICO U.S. Record of Deportable/Inadmissible Alien First Middle M Paupon Numbcf And Ccwmy or lst Entry Pu.Senger DoaJded ;Lt and Cwntry or Pmnancnt Residonco CALLE 12 NOVIEMBRE S/N SAN JUAN DEL RIO, QUERETARO, MEXICO Dlleor Binh 02/13/1985 City, Province (Smtc) ,ml Counuy ofDinh Age:28 SAN JUAN DEL RIO, QUERETARO, MEXICO O:ueof Action 01/23/2014 AR IE] PB l.oc:,ticn Code LAREDO, Form; (Typ.,nd No.) Lifted O Net Lifted 0 Soci:sl Security Account N11mc, O.tc v, .. Issued Scc11I Scaaity Numbct Jmmisn:tion Record D1ttiHour 01/23/2014 1730 At/Neor LRT/LRS N!V Issuing Post ond NlV Numbct !I Single □ Divo,cod □ Married □ Widowo, □ !«I TX By (b)(6); (b)(7)(C) StHUS " Enuy St:uus When Fcund TRAVEL/ PWA Mexico Lenglh cf Tune lllrg&lly ,n U.S. AT ENTRY CrimiMl R.ccotd POSITIVE - See Narrative Nome , Address, and N ,tiona lity or Spouse (Maiden Name. if Appropriate) umber .1.nd NatioMlity or Minor Children Moet's Present And 1',,b.idcn Names, Natiomlity. And Address, If Keown FOlhet"s Name. Nauoruhty, IJ\d Address. if Known See Narrative Monies Dur/Property in U.S. Not 1n fm.medl.Dtc Posses.$ion None Claimed See Narrative Fingerprinted? fil Yes O No Charge Code Word>(s) I7Al Type or Employment Name and Address of(LaSl)(Currcnt) U.S. Employer Employed from/to Hr Namtive (OlA.linc pmic:ul;ar, undO" which alien wu loca1ed'apprchcndcd. Include detail$ no1 shown above rcprding time. pllcc ind tn1Mcr of b.st entry. .aittcmplcd c-ntry. or any other entry, 11nd clcmcntJ '11o-hich �blish 1.dministr.1rivc and/or crimim:J violation. Indiatc meam ;and roule 1.t1vtl to in1erior_) FINS t:17851616 ARREST COORDINATES: or I77 #:NO PROPERTY Right Index Print Left Index Print Latitude: 27.49465 Longitude: -99.48399 CONSEQUENCE DELIVERY SYSTEM: Classification: SOTA Alien tw � ad•'UCCI Distribution: ER MAG COURT or communication privil�es b)(6); b\/7\/C\ !(b)(6); (b)(7)(C) (b)(6); (b)(7)(C) (Signature ind Title of ImmJgl1li on 1cc:r Bbfd@f P&tfbl Agent Rccoivod: (Subject •nd Doeumc,iu) (Rtp0r1 of Interview) omca: llh\/R\· lh\/7\/f:\ __2_3__ , 2_0_1_4_a_t__ 2_o_s_4_______ ( time) _J_a_n_u_a_ry Expedited Removal (I-860) DBpo1,1tion. on: Ex:amin.i ny Officer. l(b)(6); (b)(7)(C) Fonn 1-213 (Rev. 08101/07) Y 2020-ICLl-00006 773 U.S. Department of Homeland Security Cootiouatioo Page for Form Alien's Name KBRNANDBZ-RODRIGUBZ, JBIFRI ALKXANDBR Program.: File Number A206 418 141 _ _ Bvent No :,-l(b-)(7)(- E) ----.I I213 Date 01/23/2014 STR PROS OTIIBR ALIASES ICNOWN BY: HBRNAHDBZ, JBFRBN 09/22/1987 PATHBR NAMB AND ADDRBSS: �I Nationality:MBXIco�(bl )_ (_6l_;(b_ )(_ 7)_ (C_l____ SAN JO'AN DBL RIO, QOBRBTARO, MEXICO MOTBBR NAME AND ADDRBSS: Nationality:MBXICO fb)(6); (b)(7)(C) SAN JUAN DBL RIO, Q'D'IIRBTARO, MBXICO ASSISTING ASSETS: scopes rmms IH POSSBSSION: united States Dollar .oo (b)(?)(E) HARRATIW: ZOHBS: Entry Zone: Z9.10 Apprehension zone: Z9.10 BNCOUNTBR1 A Laredo Sector Border Patrol Agent encountered the above subject in the Doc P's property, in Laredo Texas, Webb County. After a brief interview, it was determined that the Subject Signature r b)(6); (b)(?)(C) I Title Border Patrol Agent 2 3 ___ of ___ Pages Fonn 1-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 774 U.S. Department of Homeland Security Alien's Name HBRNANDBZ-RODRJ:GUBZ, JBJ:PRJ: ALKXANDBR J:213 Continuation Page for Form File Number A2 0 6 418 ""1""' 4=1'"'=_____,, ---�I Date 01/23/2014 Event No 1 ._ l(b_)(_?)_(E_) had unlawfully entered into the Unitec States t:rom Mex.1co and was not at the t e inspected or admitted by an Immigration Officer at a port of entry as designated by the Secretary of Homeland Security. Subject further admitted to being a citizen and national of Honduras with no right to be in or remain in the united States legally. The subject was placed under arrest and advised of their rights. CRDIINAL BJ:STORY1 See attached record checks. IMMIGRATION HISTORY: See attached record checks. BBALTB SCRBBNDfG: Subject claims no illnesses or injuries. CONSULAR NOTJ:FICATION: The Subject's right to romm,,1oi�ate with a Consular Officer of the subject's native country was offered. Subject understood and declined the right to contact the Consular Officer at this time. Subject does not claim fear if returned to their native country of citizenship. Signature (b)(6); (b)(7)(C) Border Patrol Agent: 3 3 ___ of___ Pages Fonn 1-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 775 U.S. Dcpartmtnl of Homeland Sccurily Record of Deportable/lnadmissiblc Alien Subject ID: !/b)(?)(E) Family N&mo (CAPS) F,m Middle HERNANDEZ-RODRIGUEZ, JEIFRI ALEXANDER l'llJspOtt Numbct .. d C""11t,y of!5'ue Fila Number Country or Ciutenship CASB No �{pl'?J!F} MEXICO 1 A206 41 U.S. Address Hair BRO Weight 1Ieigh1 130 62 SCilrs and Marks NONE VISIBLE Pancngcr D�dcd 111t D111te,. Pia.co. Time, 11nd �b.Me:r ofLut Entry 01/23/2014, 1700, 1.42 mile(s) E ot I.AR, PWAM Numb«, Su-c:et, City, Province (State) and Country of Prnnancni Roidi:ncc CALLE 12 NOVIEMBRE S/N SAN JUAN DEL RIO, QOERETARO, MEXICO Location Code O:ue of Dinh Ihtc of Action LRT/LRS 02/13/1985 01/23/2014 Age:28 Cuy. Province (State) and COWIU')' of Binh R IE) Form: (T)1>le) Cn,pb,n Eyes MED BRO Occupa:Uon LABORER Number and N,cionality of Minor Childr(6->: -�I I Searc:h Results · SubIact , � . f!rl2n. · A: 10 __; N �m�!_r_ :�IQ__........., m_____ _; No link (b)(?)(E) , i, No link l=$50 < $500 OFFENSE PC 31. 03 (e) (2) (AI) CITATION OFFENSE DESC M0666423 LEVEL & DEGREE MISDEMEANOR - CLASS B HELD DISPOSITION 04-08-2006 DISPOSITION DATE TX05701SA - CRIMINAL DISTRICT ATTORNEYS OFFICE REFERRED DALLAS QUEUE TYPE: PERSONAL PROSECUTION DATA 2020-ICLl-00006 802 22:45 QUEUE TYPE: TECS II EXTERNAL MESSAGE DISPLAY 0123 2 014 (b)(?)(E) PERSONAL QUEUE NAME: (b)(?)(E) MSG STATUS: .........,. ******************** TEXT OF MESSAGE *******�* �*�*.........,.*** PAGE 05 *************** DALLAS ACTION PROSECUTOR ACCEPTS THE CHARGE OFFENSE THEFT PROP>=$50 < $500 CITATION PC 31. 03 (e) {2) (AI) OFFENSE DESC M-0666423 LEVEL & DEGREE MISDEMEANOR - CLASS B COURT DATA COURT AGENCY COURT OFFENSE CITATION LEVEL & DEGREE DISPOSITION DISPOSITION DATE TX057303J - COUNTY CRIMINAL COURT NO 5 DALLAS THEFT PROP>=$50 < $500 PC 31. 03 (e} (2) (AI} MISDEMEANOR - CLASS B CONVICTED 04-20-2006 (b)(7)(E) 2020-ICLl-00006 803 22:45 QUEUE TYPE: TECS II EXTERNAL MESSAGE DISPLAY (b}(?)(E} 01232014 � r b)(7)(E} - - - -� QUEUE NAME : MSG STATUS: ******************** TEXT OF MESSAGE **************** PAGE 06 *************** CAUSE NUMBER M-0666423 FINAL PLEADING NO CONTEST OR NOLO CONTENDERE CONFINEMENT 30D FINE 800 249 COURT COST RECEIVING CUSTODY TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE =============================================================================== EVENT CYCLE 2 l(b)(?)(E) TRACKING NUMBER I ARREST DATE 07-11-2008 TYPE ADULT TXDPDOOO0 - DALLAS POLICE DEPARTMENT AGENCY HERNANDEZ,JEFREN RODRIGUEZ NAME PERSONAL (b)(?}(E) 2020-ICLl-00006 804 22:45 TECS II EXTERNAL MESSAGE DISPLAY QUEUE NAME: (b)(?)(E) MSG STATUS: ******************** TEXT OF MESSAGE**************** QUEUE TYPE: PERSONAL OFFENSE DATA AGENCY ID NUMBER AGENCY CASE NUMBER OFFENSE AGENCY OFFENSE DATE OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE DISPOSITION DISPOSITION DATE REFERRED 1024266 01232014 �r b )(7 )( E) � - - - -- PAGE 07 *************** I TXDPD0000 - DALLAS POLICE DEPARTMENT 07-11-2008 PROSTITUTION PC 43.02(a) M0B60167 MISDEMEANOR - CLASS B HELD 07-11-2008 TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS !lh)CZ)/F\ 2020-ICLl-00006 805 22:45 TECS II EXTERNAL MESSAGE DISPLAY 01232014 (b)(?)(E) (b)(7)(E) QUEUE NAME : MSG STATUS: ******************** TEXT OF MESSAGE ********------ * PAGE 08 *************** PROSECUTION DATA PROSECUTION AGENCY TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS ACTION PROSECUTOR ACCEPTS THE CHARGE PROSTITUTION OFFENSE PC 43.02(a) CITATION M-0860167 OFFENSE DESC MISDEMEANOR - CLASS B LEVEL & DEGREE QUEUE TYPE: PERSONAL COURT DATA COURT AGENCY COURT OFFENSE CITATION LEVEL & DEGREE DISPOSITION TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS PROSTITUTION PC 43.02(a) MISDEMEANOR - CLASS B CONVICTED 2020-ICLl-00006 806 � 22:45 QUEUE TYPE: TECS II EXTERNAL MESSAGE DISPLAY PERSONAL 01232014 r b)(?)(E) QUEUE NAME: MSG STATUS: ******************** TEXT OF MESSAGE *******• PAGE 09 *************** DISPOSITION DATE 05-12-2009 SENTENCE DATE 05-12-2009 CAUSE NUMBER M-0860167 FINAL PLEADING NO CONTEST OR NOLO CONTENDERE CONFINEMENT 45D FINE 400 COURT COST 313 TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY =============================================================================== EVENT CYCLE 3 l(b)(?)(E) TRACKING NUMBER I 04-25-2009 ARREST DATE TYPE ADULT TXDPD000O - DALLAS POLICE DEPARTMENT AGENCY HERNANDEZ,JEFFRY NAME l(b)(?)(E) 2020-ICLl-00006 807 22:45 TECS II EXTERNAL MESSAGE DISPLAY QUEUE NAME: (b)(7)(E) MSG STATUS: ******************** TEXT OF MESSAGE **************** QUEUE TYPE: 01232014 (b)(?)(E) PERSONAL TRACKING SUFFIX PAGE 10 *************** A00l OFFENSE DATA AGENCY ID NUMBER AGENCY CASE NUMBER OFFENSE AGENCY OFFENSE DATE OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE DISPOSITION DISPOSITION DATE 1099043 l(b)(7)(E) I TXDPD0000 - DALLAS POLICE DEPARTMENT 04-24-2009 LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 M0955596 MISDEMEANOR - CLASS UNKNOWN HELD 04-25-2009 2020-ICLl-00006 808 22:45 TECS II EXTERNAL MESSAGE DISPLAY QUEUE NAME: (b)(7)(E) MSG STATUS: ******************** TEXT OF MESSAGE**************** DALLAS QUEUE TYPE: PERSONAL PROSECUTION DATA PROSECUTION AGENCY ACTION OFFENSE CITATION OFFENSE DESC LEVEL & DEGREE l(b}(?}(E} COURT DATA COURT AGENCY COURT OFFENSE CITATION 01232014 l(b-)(?-)(-E) --� � PAGE 11 *************** TX057015A - CRIMINAL DISTRICT ATTORNEYS OFFICE DALLAS PROSECUTOR HAS CHANGED THE CHARGE LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 M-0955596 MISDEMEANOR - CLASS B TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 2020-ICLl-00006 809 22:45 QUEUE TYPE: TECS II EXTERNAL MESSAGE DISPLAY 01232014 (b)(7)(E) QUEUE NAME: (b)(?)(E) MSG STATUS: ******************** TEXT OF MESSAGE **************** PAGE 12 *************** LEVEL & DEGREE MISDEMEANOR - CLASS B CONVICTED DISPOSITION 05-12-2009 DISPOSITION DATE SENTENCE DATE 05-12-2009 M-0955596 CAUSE NUMBER FINAL PLEADING NO CONTEST OR NOLO CONTENDERE CONFINEMENT 45D 100 FINE 253 COURT COST TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY PERSONAL TRACKING SUFFIX A002 NO OFFENSE DATA AVAILABLE l(b)(7)(E) ---------------------------------------------------------------------- 2020-ICLl-00006 810 .""'"\ 22:45 QUEUE TYPE: 01232014 TECS II EXTERNAL MESSAGE DISPLAY PERSONAL QUEUE NAME: MSG STATUS: ******************** TEXT OF MESSAGE ******** NO PROSECUTION DATA AVAILABLE COURT DATA COURT AGENCY COURT OFFENSE CITATION LEVEL & DEGREE DISPOSITION DISPOSITION DATE SENTENCE DATE CAUSE NUMBER FINAL PLEADING CONFINEMENT FINE COURT COST ** �l(b_,�_,(_E_) __ PAGE 13 *************** TX057283J - COUNTY CRIMINAL COURT NO 4 DALLAS LEWD/IMMORAL/INDECENT CONDUCT ABC 104.01 MISDEMEANOR - CLASS B CONVICTED 05-12-2009 05-12-2009 M-0871060 NO CONTEST OR NOLO CONTENDERE 30D 750 249 2020-ICLl-00006 811 22:45 TECS lI EXTERNAL MESSAGE DISPLAY 01 2 3 20 1 4 l (b )(? () E) � - - - --� QUEUE NAME : (b)(?)(E) MSG STATUS: ******************** TEXT OF MESSAGE**************** PAGE 14 *************** TX0570000 - DALLAS COUNTY SHERIFF'S OFFICE RECEIVING CUSTODY -----=========-==================================================-------------NO CUSTODY DATA AVAILABLE UNAUTHORIZED USE OR DISCLOSURE OF THE INFORMATION CONTAINED IN THIS RECORD MAY RESULT IN SEVERE CRIMINAL PENALTIES. SEE TEXAS GOVERNMENT CODE SECTION 411.085. END OF RECORD CRIME RECORDS SERVICE DPS AUSTIN TX 01/23/2014 ***END OF RECORD*** QUEUE TYPE: PERSONAL l(b)(?)(E) 2020-ICLl-00006 812 LEAVE BLANK CRIMINAL STATE USAGE FD•249 (An 3· \•ID) LEAVE BLANK (STAPLE HERE) □ D D jUUMISS O•, HERNANDEZ-RODRIGUEZ, JEIFRI ALEXP.NDER S,�,t.iAn ;, Of t �RSON FINCiEr◄Pl11�ffEO 5-XIAcl. �[CUHITY �JO r :::r: Af.lASLS.�l•dOE.�-l .,sT r�6.'.�.E I=.', T ·.A'.'f. ,,,,1) l!ERNll!IDn. ��AME SUH[), JnREN (b)(?)(E) CATE Of l3Hllt� 9 LF FOUR rn,c;rns TM,ta S,MUcTI\NEOUSLY Ji· �- , , ,o-oo•e FEDERAL BUREAU OF INVESTIGATION, UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION.CLARKSBURG, WV 26306 ,n,ormat on iS genorally authorUed under 28 USC 53-1. Tr s F0•249 Tr a FBI s a:qu1�1t•on preservat,on. a.no exChanqe ot dun ,f, e us.color cmmnnl Ju.:::i11co purposes, such� 1nCK1en to urrC:S-1.S nnd l,X !WM< Reduct nn Act and Pnvacy Act notices and shcu d � �•e<: ncrtm·n;il 1us11c� purposes "A Social Secvm ,\caiunl lurr,ber (SSArll ,�c,1rcarn11ons Toe App ,coril lnrrn I FD-258: conl.l,n app•..: s , 'plut IO l-2•9 ( R_,, ). M Q) (b)(?)(E) Ofil JU\'E'llLE �WGL �PRINT onE or AAf\lS i YES UtH,HS:S I OrJ fAl"A" A -'OULT YlS I □ □ '•"·b 1 /23 (to 14. AIHlHE 5" �EPt.V vrs 0!51A[0� □ (Bl-!!PS'l(OLIS NUt.rnrns COtH!1IBUrOR C1R caur.u;v1 QUERETARO,MEXICO COl/rJTllY or Cl I/UJSHIP MEXICO AMPU1AT10fl� AR-206418141 ,=--p ,!!: l'f-'d'S16 I(. �E, IUErH.;E1COM'PLETE- AD RE 5 OFFICIAL TAKING r-rnGEf\PRte,TS 1,1,.,_•�t: r,,r1 � 11u1�ra1 r b)(6); (b)(?)(C) E.M?l.O'fER c rv SAN JUAN DEL CALLE 12 NOVIEMBRE S/N I 1..0CAL mErJTlFICA {b)(?)(E) RIO 1orJ,'HETF R'E. NCf I IF' Lis GOv[rtr�,.•ENl INt)ICATE SPl:ClflC A(ilNCY IF MII.ITAflY LIST BHA'ICH or So'lVICl; Arm S[nlAL r10 OCCUPATIC'r LABORER CHARQE,CITATtON 201,0123 - ENTRY WITiiOlrr :tiSPECTlOH, T;�,E OH Pl.ACE NOT PES !CNATED 20140123 - AL!El/ INADM SSIB!!..ITY UNDER SECTION 212 0 I Sf10S1T10�l I Pending i 1, J .\OOl"'!OtiA A�OITIO'�AL .\UOIT10Nt�L ltH-ORMAflON1f1AS1S �OR C,\Ul10N STArt UUHE�U SUMP (;· U.S. GOVER" ENl PRHITIIIG OFFICE:0711 1201J09.:3 r:, 2020-1 C Ll-00006 814 :S1"ATI:. QU MM et◄O�O AVAILAOLE VES PALM ��·ti f', TA�Etl ? ns □ □ Consequence Delivery System Form LRT/CDS-100 Subject Information Event �'::> \-40 \ 26-q-- se::r� \ �� 21 v, l �s-- C0 Name DOB �t Country A# (b)(?)(E) l Entry Date I Zone (z; di-'?? App. Date Zone °1 1 Use the following information below to complete the A-File. VR MAG/VR ER MAG/ER WA/NTA Reinstate IT MAG/REINST MAG/REI 1326F JP Date: Program Classification Dis osition □ □ □ FIRA SOTA PERA CRMA FMUA SGDA TGDA □ □ □ □ □ □ ATEP STR PROS Streamline CCA POE Yes No □ □ � □ Subject to further review upon additional records checks discovered. ,g_4\io14 N b)(6); (b)(?)(C) CDS Agent Star# I Last Name United States Border Patrol - Laredo Sector Processing Center - January 20, 2013 2020-ICLl-00006 815 LRTPC DETAINEE FIELD INTERVIEW SHEET . LR N . LR W . HEB . CAR , FR R . LZT . CDT . Circle one -- j1 □f J_ I * '··All gre'1 pnrlinns must be lilied out COMPlETH'f and lfGIBl'f hy licld Agents ur hudy/badies may be �EJECTEO" • • First name: last names: Middle name: 0-.f AGE: Juvenile? □ ale: I /,).3 Entry Zone: Yes fime: /7:oo �- t 6 D Operation: 0 Phalanx Accompanied or Unaccompanied? Entry: localiort Dol, l's •:,HII 1lf 1 tJ I . I . , � Jj , l j . 0 Ila!. Guard Currency -: -- in -Possession: . ;. USO$ MXN $ ;□ ther $ I I /Other I $ 1Subject's initiols: X 1b1 �q 4,,c fime: /7 s¥f localion: ()u ro j) i .. _ '.Medicine bag #: .iPrape�ty ba� #: I ,Maney bag#: a STAR #'s: ' wJl f.//J D Other BP: (f x: Brush/Bus Crew. SOG. etc ... ) D Non-Border Patrol: DICE OOPS □ Other: ·1:rn .. �11•• nm..·lol utotJ11;s, � ·- . . Pw-rp, D Polirn: 0 Sheriff: """' lin,la,�1:r#",...na,gmullip/1,g,ncios j _o -�CJJ1 � ~ Event#: Notes: iFINS#: ' 1 FBI#: / Smuggling Case Info 6051s#: lntuklng Agent's Star Is Apprehension Zone: County: Apprehension Assists: )Zl Cameras D K-9s: D Horses D M11rine/Watercrafts D Scopes ' D Sensors Apprehending/Assisting Agents' LAST NAMES I Dula: Apprehension: GPS: N.J±]__. W.!j!/_... 1/f 'Write GPS coordinates in Decimal Degrees ONLY. □ Orher. □ ATVs·-· .,i,, - · □ Air. Ops: □ OPS □ CBP □ Bikes Citizen of? #: 1�gent's !niti�ls: "Allen does not retain currencyunt//!Ina/ disposition is o/Jtalnetl. 2020-ICLl-00006 816 I I of Case of: Mat Wit: Y or N I i I frnsGEN LS Z9.I Z9.2 zg_3 l9A l9.5 l9.6 Z9.7 rn.B ZS.9 ZS.I D ZS.II Z9.12 l9.13 l9.14 Z9.15 ZS.IS ZS.17 ZS.1B ZS.IS Z9.20 Z9.21 Z9.22 Z9.23 l9.25 Z9.26 • Z9.2B Z9T.I Z9T.2 Z9T.3 Z9T.� l9l.5 ZST.6 Z9T.7 ZID ZI0.1 ZID.2 ZI0.3 ZIOA ll0.5 ZI0.6 I.RS GENERAL AREA. NDN-SPECIAC SANCHEZ ST. 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I've followed up with him to confirm the following, but I read this to say: HERNANDEZ physically arrived at SLDC at 1800 hrs on 5/14/2018, and was released from SLDC (bound for El Paso) at 0001 hours on 5/15/2018, for a total of 6 hours physically held in SLDC. I believe ICE staff in previous communications mentioned this six hours, but it wasn't clear to us at that time where that number came from. We can use this in the timeline (let's not use EARM). Let me know your thoughts, l(b)(6); __ I From: !(b)(6); (b)(?)(C) Sent: Thursday, August 9, 2018 6:47 PM To: rb)(6); (b)(?)(C) I------------------ Cc: Subject: RE: HERNANDEZ DOR Attached you will find the 1-203 from the San Luis Detention Center indicating that the Detainee Hernandez was physically present at their facility, arriving on 05/14/18 at 1800 hours and departing on 05/15/18 at 0001 hours. Copied on this response is (A) AFOD !(b)(6); (b)(7)(C) !who can give a better description regarding San Diego processes of staging and transferring of cases. Hope this helps. kb\/6\: (b\(7\(C\ AFOD From: !(b)(6); (b)(?)(C) Sent: Thursday, August 9, 2018 12:49 PM To: l/b\/6\: /b\/7\/C\ Subject: RE: HERNANDEZ DOR Great thanks! Since I will have one other person on the line with me remotely, do you mind calling into this number? (b)(6); (b)(?)(C) 2020-ICLl-00006 818 Kb)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 73 (b)(6); Cell: (202) 270- �}(7)( l(b)(6); (b)(7)(C) From: kb)(6); (b)(7)(C) Sent: Thursday, To:l(b)(6); (b)(7)(C) Subject: August 09, 2018 3:37 PM RE: HERNANDEZ DOR Yes I can be reached at 760-768� Sent with BlackBerry Work (www .blackberry.com) From: l(b)(6); (b)(7)(C) Thursday, Aug 09, 2018, 12:14 PM To: l(b)(6); (b)(7)(C) Date: Subject: RE: HERNANDEZ DOR Sorry for the delay. Would you be able to talk at 4:15p EST (1:15p your time I believe)? l(b)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 73 (b)(6); l( Cell: (202) 270- �t !/bl/6l: /bl/7l/Cl From:l(b)(6); (b)(7)(C) Sent: Thursday, August 09, 2018 12:34 PM 2020-ICLl-00006 819 To: l(b)(6); (b)(7)(C) Subject: RE: HERNANDEZ DOR Good morning, I am available today for the next two hours and once again from 1-3 in the afternoon. I will be on leave tomorrow and will return Tuesday the 14th . Best, From: !(b)(6); (b)(7)(C) Sent: Thursday, August 9, 2018 5:38 AM To: (b)(6); (b)(7)(C) l I Cc: ----------------� Subject: HERNANDEZ DOR (6); Good morning AFOD (b) /h\171/rl As you may know, I am a Team Lead at the ICE Office of Professional Responsibility and am in the process of conducting a review of the death of detainee HERNANDEZ, Jeffry !lb\/6\: /b\/7\/C\ L As part of our timeline, we include all movements and activities related to the deceased detainee starting with when they enter ICE custody. Although HERNANDEZ died while in the custody of ICE at Cibola, we have some gaps in information starting with San Luis. We would greatly appreciate if you would be able to speak with me and my team members to try to help close the loop on these outstanding questions. If possible, could we schedule a telephone call with you sometime this week? Respectfully, Kb)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 732 b)(6); Cell: (202) 270- br)( (b)(6); (b)(7)(C) 2020-ICLl-00006 820 ..... _. ............. ORDERTO --- ..-----·----···· ----��----�--- .·-·---·-·-·--· Detain. Detain (b)(6); (b)(?)(C) NAME ' POUCH NO. AGE 29 8G 19 M M 8G 24 M 18 M 33 M 24 M BG 26 M [ BG Z1 M - 23 j i. f. jHERNANDEZ 8G I � 8G )JEFFRY (b)(6); (b)(?)(C) ! ! i . FINGERPRINTS i j 8G BG 8G SEX 22 Signalure Detention Office,, Sherift, etc. (Receiving Officer) Forni 1-203 Phila. M M I l i l ! I ! i I . i I BIRTHDATE NATIONALITY .Month/Dale/Year HONOU b)(6); (b)(?)(C) AUEN NUMBER ! HONDU HONDU I HONDU HONDU i I 2/18/1985 HONDU j b)(6); (b)(?)(C) HONOU Ii GUA1E i j MEX.IC i GUATE ! �, A206418141 ! ' ! ! b)(6); (b)(?)(C) Data 5/14/2018 i i ! i ! i i lO i LO LO LO �DC �RE . CJ?,P DATE; b)(6); (b)(?)(C) TIME:.__,_:..>,<..,;�""""' RECBVl:=D BY: <§) �.£A1� f#Yf���--____, 2020-ICLl-00006 821 ! i I LO ii REMOVAL PREVIOUS Criminal Hislorv NC NC NC NC Illegal EntJy LO i i NC LO i NC LO LO LO AM � j 1 , of 2) I ANS NUMBER ! (b)(6); (b)(?)(C) ' ! i ! ! l i ! 17851616 b)(6); (b)(?)(C) NC NC NC PHOTO __. :>ifedlrlg Action DEPARTMENT OF HOMELAND SECURrTY- US IMMIGRATION AND CUSTOIAS ENFORCEMENT USMS / Al-. USMS f CA USBP Manifest No. 722009 (oaae 1 NAME OF FACIUTY; SAN WIS REGIONAL DET CENTER Nature of Prcceedings TO: SAN DIEGO, CA Pleal!! detain or reJease lhe following ALIEN Date Station 5/14/2018 ! Detain ORDER TO TO: ALSUQUERQUE, NM Please detain or release !he following Detain b)(6); (b)(?)(C) POUCH NO. 8G NAME 8G AGE 29 8G BG 8G 8G tERNANDEZ 8G jJEFFRY [ b)(6); (b)(?)(C) i ! . FINGERPRINTS SEX M M 19 M 24 18 M 30 M M 35 M 33 8G 24 M 8G 24 M 8G M 26 I ! � 1 i ! I i ; f ! - NAME OF FACILITY: CIBOLA COUNTY CORRECTIONAL CENTER Nature of ProQledings REMOVAL PREVIOUS CLS BIRTHDATE ALIEN ANS NUMBER CODE Criminal History NUMBER NATIONALrrY MonrNDate/Year NC [ (b)(6); (b)(?)(C) HONDU (b)(6); (b)(?)(C) b)(6); (b)(?)(C) � LO l HONDU HONDU HONOU GUATE HONDU HONDU ' ! ; 2/1811985 b)(6); (b)(?)(C) I LO I ! LO � LO NC ! NC ! LO � 1 i 1 NC � � i j . LO i LO IQ i I i � !Degal Entry i NC NC 5/15/201 � b)(6); (b)(?)(C) ! j �i � ! Date recting Action Date 17851616 I NC � PHOTO i ' NC LO � ; i NC I A206418141 . LO � (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) HONDU HONDU I i HONDU Signature Detention Officer, Sheriff, etc. (Receiving Officer) FOITTI 1-203 Phila. Manifest No. 722019 {page 1 of 2) ALIEN Station 5/15/2018 DEPARTMEHT OF HOMELAND SECURITY- US IMMIGRATION AND CUSTOMS ENFORCEMENT DETAl�7� USMS / AZ FAS-;/ DATE: 5 · ( � s� 1 7J USMS�A TIME: ECEIVED BY: USBP -�BY: QiP• · (b)(6); (b)(?)(C) b)(5); (b)(?)(C) 2020-ICLl-00006 822 ConductedJb:.: DATE: --..�=r-,::,-::-r--r-----__,...-­ TJME: __.J.t,�';4------ l(b}(6}; (b}(7}(C} From: Sent: To: Cc: Subject: Attachments: 4 Jun 2018 13:28:55 +0000 l (b}(6}; (b}(7}(C} Hernandez - Prelim Mortality Review Preliminary Mortality Review Report_HERNANDEZ_FINAL.PDF See attached. !(bl(6l: (bl(7)(C) !Unit Chief ICE Office of Professional Responsibility External Reviews and Analysis Unit Office - (202) 732- b}(6}; 90 b}(?}(C} Mobile- (202) 2020-ICLl-00006 823 Page 824 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 825 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 826 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 827 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act From: Sent: To: fbl(6l: (bl(?)(Cl 8 Aug 2018 14:11:08 +0000 b)(6); (b)(7)(C) Cc: Subject: H Hernandez Follow-up (b)(6); ey /h\f7\trl I've been trying to track down information on the detainee's movements prior to her admission to Cibola as we'll need to cover it, to the extent we can, in our report. I spoke with the IHSC investigator earlier this week, and have a call scheduled with the DFOD in San Diego this afternoon. I'm hoping he can walk me through what happened with the detainee, at least generally, and identify a POC who can provide more detailed information. That said, once I get a POC, I'd like you set up a telephone interview with that person either Thursday or Friday this week - �ill participate in the interview with you so that she ensure all the loops are closed in CC's report as well. Please plan to come into the office tomorrow as l(b)(6); !will be here to drop off a laptop and is planning to touch base with you on the outstanding questions. I won't be able to sit in on the interview because I'll be in training Thursday and Friday, but you know far more about the case than I do anyway, so I'm sure you can handle it. I'll be in touch this afternoon after I talk to the DFOD. Thanks, Kb)(6);__ I 2020-ICLl-00006 828 From: Sent: To: Subject: !(b)(6); (b)(?)(C) 14 Dec 2018 13:52:54 +0000 l(b)(6); (b)(?)(C) FW: OMI 2018-03102 Hernandez Rodriguez I FYI Sent with BlackBerry Work (www.blackberry.com) From:l(b)(6); (b)(?)(C) Date: Thursday, Dec 13, 2018, 8:53 PM To: 1(b)(6); (b)(?)(C) Subject: FW: OMI 2018-03102 Hernandez Rodriguez The latest. Not sure if you already received this. fb)(6); (b)(?)(C) SDDO ICE Albuquerque 505-235l(b)(6); f Fromkblf6l: fbl/7)/Cl Date: Thursday, Dec 13, 2018, 11 :33 (b)(6); (b)(?)(C) Subject: FW: OMI 2018-03102 Hernandez Rodriguez Good morning, Please see response from ME office in Albuquerque. I also spoke with!(b)(6); (b)(?)(C) �nd again and stressed the importance of getting the finalized report froml(b)(6); IASAP. 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Ending Mileage i50q33 £1No Start Time J 530 End Time Date sltll}tt /13t:J Present Male 1.3 Unloade Male 13 · Female· Fem.rue ft ff 13 /5 Total Total Ending mileage g_s Total on Male f1 Female f:1 Total /f Time � 1�� �:.':�··_t::.:�:.,i _ {���..::�::·��r.�:·� ('i:��W#¾'.::��!�1 -��-��f:�:':",�f.-�:f-�:=-���f(-��;¥.�xi:=»�w�;-��-;.��:�;:,;-;f.s.::�::-::���J.;-;.t:ii?¥:'i:®:��-�r�-:,.�-::�1t�-:t�•q:::}f;�-':tf:.-.::-��v.:g·�M.";:����,(f���J:'.=f-.=.::.��:::�:i-:::,�-:-i��-�c-"J:�1�.�;;#���q-.:Ntj Transport Officers Date - sl JI.I 1to (b)(6); (b)(?)(C) End Titne Total miles Start Tune Date ll3D 5 /,1.1ht /131) 11D Tune 5\u SLRDSC Transport Trip Log _ 2020-ICLl-00006.........976 _ _ ------------------.. •..... LaSalle Corrections West San Luis Regional Detention and Support Center Transport 50 Passenger Bus Seating Chart I �(b)(6); (b)(7)(C) 3. 5. 7. 9. 11. 41. 43. 45. 47. 49. Officer. �toe .. -rn . 22. 24. 26. 28. 30. 32. 34. 36. 38. 40. 42. 44. 46. 25. 27. 29. 31. 33. 35. 37. 39. (b)(6); (b)(7)(C) b)(6); (b)(7)(C) 1!t 20. 17. /-1,. '""''� J n 19. tb)(6), (b)(7)(C) 21. 23 Officer: 4. 6. 8. 10. 12. 14. 16. 13 [b)(6); (b)(7)(C) 15 Bus# 1(b)(6); I Destination/Route: 2. .. 48. so. I 1-krc.. Date: 5 /14 ltl · l Officer: Officer: 2020-ICLl-00006 977 . Form 1�216 M,11ifesf No. __3_722-'---0--'-19_.(.._aP ..,_g_a _t """of_1,_) _ US. DEPARTMENT OF HOMELAND SECURrrY IMMIGRATION & CUSTOMS ENFORCEMENT {Re�.04/26/11) FROM: SAN LUIS REGIONAL OET CENH Origin FO: SAN DIEGO. CA FIie No, I riame or PE rsi,n FIRSl I.AST I I , (b)(6); (b)(7)(C) I I VIA(1)_�-VIA(:Z) ____ DOB Nallon,;.llly HONOU -·7=roIBu TO: CIBOLA COUNTY CORRECTIONAL CE? Oest. FO: ALBUQU£RQUE, NM 51.'IIUS (1) 8G 813 ..- HotT□u-·· .._,__SG ___ ·- HONOU 80 ,_ HO}'IOU�- -··-iG--GUATE -· -··HONOU - S Q-·--�·- A2064181�1 IHERNANO_EZ ·. (b)(6); (b)(7)(C) ··- I .,.,,a,o� .lffi.FrNT - HON--i:m- --·"aG--· --«owffiJ· HONDD 80 8G -GUA'fe--i:iexic-- ,-.-·7G-- . 7-k>NDU-- ... -�-8G ___ �NDU 8G Mex1c �- Gll1!.IL_ HONOU -·HON� HO,�Q.U I certfty comp (b)(6); (b)(7)(C) I Name.ndllUe: {1) • Showwh .• V -· - Transfer Oate: ___o_5/_1o-"-f_18___ RECORD OF PERSONS TRANSFERRED ~aG-· 80 -718G -r8G Sex Glll'lg Memberahl!> Crlmln.al HiG!ory M·- N Nf M N N N N NC ��-·,...:_--- �g-� e-i- MC NC 1115al� M M ·:��·- NC _::--NO ,� NC NC Ms :M NC NC .. M NC NC NC NC NC �- M M M - c(ese. Level LO ti--- ·-- .._.,LO rr·..-·.--t} N N N N N H Ill ·--NN g-. -tu'iLO -..:1§- ----·- _:_:�-N--N • To··· N MODE: ______ Other: _______ -- Fine# .. -- .. , --•-•-·-R- -· 17�1616 ...... ,_ --·- t-·-- Use I sep"'81e line fur each l)llr;;on tr11ntferr�. This rorm la lo be axeCU1ed In sufflclent n1N11ber ol ccpl!,$ to allow receMng otlloerto retain oae CDJIY of his �I �e voucher end two lddlllonal copies for 6tal!on ol flnal dell�ty. Comments (2} I 381!i278�- (b)(6); (b)(7)(C); (b)(7)(E) ---·-· LO Signature: 11tle: PIHCeandDele: 2020-ICLl-00006 978 (b){6), (b)(7){C) -· _,_.,,_, LO l - ----· ,__1,;9__ :---· LO 1.0 - _,,...,_ ---- I Contact Number(&); whelher NTA or Flt131 Oroer '/0) (2} • Show medi 021 eoricll�cns, l\igh rlsk, fil 91lt risk, epileptic, ins 11!1&, e\c.. Subject IC ...._ ransfer Slanr:taras and ICE Air Boarding , equlrements for tnts ICE Air/Cf,orter movement �Office; 1 b)(6); (b)(7)(C); (b)(7)(E) I U Fllght Officer In Charge ICE Air �rat�ns-HO LASALLE CORRECTIONS TRANSPORT,L.L.C. Transport Trip Log Paperwork .Facility Van D Car Vehicle number: . Start Leg Loaded At Starting Mileage CE Bus (b)(6); (b)(7)(C) Present Male D Female dLDC- Loaded Male l?\. \q Female Female 1-- 0 Total \f " \ r 4 ! Loaded At Present Male Me--it.A1 0 Female A?r '24? □ �o?P3B 0 Male d ·,C Female Female � ���-- 0 Total c) Ending Mileage 303-03t) No :End Ti'me Date 0 vlo Total 1--� (Jt._, Male it r Fem.ale Total ,.:::(b)(6); (b)(7)(C) } s - b Female 0 Total Time 2- (3 tflt 0 )\ □ Yes □ Yes l� i5 \ End Leg Unloaded. at Money kd'No @N� Medicine Yes_ c·�{ Ending Mileage Date � J) C l'"3?i32-S"n @No qef Male a Fem.ale Property □ Present \ \ 1'.5 1t1i End Time l\?JP c) u Total Unloade Male CJ Female c_J Total cJ Ending mileage "f I c !'")�:.;.,,,.����*fflt-W.:t�!►-���>;:;;�··=t-f�41/�1_��@.f.�-:'�W-ci��A.o�.�;::=,,:��:t:�f!:;!;�k""B-:-..\'!";¾:;f%t��1�-:c�w.���R�.::�..M ·t.f.ftl)��-���;�l�-:.:·�:�-.::.• � ������.:-:.">��e..,.;j.��::..-:=- h,___ Male '?_(, 0 Ending mileage C) ��\8-) Start Thoe Date ..___ D 0 Total On Loaded Male 0 /J Transport Officers (b)(6); (b)(7)(C) b Total Total $ Start Time C) d Starting Mileage es �rty �ine Male tq fVle. -z..01 Female Pr7- 1- E::f"No 0No Present Unloaded Total on vc ,;:-:�;·t'��:;w;rr ·:�.. �6.�W.���:.i�-$Z-1.'.-.f;:::T��:vr--�Y�:��•���--�Y.t;-�=-��"' -'•�� :,>;,-.•o'.,,���:,,,,....,� .-·-J;i��it;¼�:,;,;}.����;;r��;.T.,�\�� �:�������·:<.��·�������..:-�·�- � . Start Leg D Total Date Transport Officers Unloaded at Money Yes -=,_ Total (b)(6); (b)(7)(C) End Leg ·Total On Male �;ljQ.c:: c) iG - of Assigned Duty Type of vehicle D Page. · San Luis Regional Detention & Supp<=!rt Center Date Start Tiine \\ 6 5\ 9! 0 0 c)b Date SLRDSC Transport Trip Log Male c::, Female C) Total � Time ct ="'"�:;°(�,1=f.:..�..P,.':;Jfj.,i;�;�»�I End Tone Total miles lt (JD i s \3 6\ \ 2020-ICLl-00006 979 ,. Total on y z_, s Time t3h� LaSalle-Corrections West Sau Luis Regional Detention and Support Center \ J -1 Transnort 50 Passenl!"er Bus2.Seatinu Chart (b)(6); (b)(7)(C) w� w . L ... � .. r:-:F7 � w �� } r:r7 � .. . . . - . . . ..... ' 4. 6. 8. 10. -� -1 .. - 12. b)(6); (b)(7)(C) - 14 18 17. . 19. 21. 23. · 2( 22 24 - 2tJ 25. 27. 29. 31. 33. 35. 37. 39. u 3( � 3, 3� 38. f-llr. v/1 ni,,1. 11 ,.,""L..J� ::fl//'T'-1 40. (b)(6); (b)(7)(C) 42. 44. 46.j 48. 50. 41. � -� 16 43. 45. 47. 49. V (b)(6); (bJ(?)(C) Bus # Destination/Route: Officer: Officer: Officer: 2020-ICLl-00006 980 t--- . ,-..... From: Sent: To: !(b)(6); (b)(7)(C) 4 Jun 2018 21:15:36 +0000 r )(6); (b)(7)(C) Cc: Subject: FW: HERNANDEZ Detainee Death Review Info Request Attachments: Cibola HSA SEN Email PDF Attachement.pdf, FMC SEN Email.pdf, Cibola Corrections Med Rec - Pt 2.pdf, Cibola Corrections Med Rec - Pt l.pdf, Ground EMS from Cibola General to Heliport.pdf, Cibola General Hospital Records.pdf, MedPARs.pdf, PHI Air Medical Transport Records.pdf, 2018_6_3 next of kin declaration signed.pdf Good Afternoon, Please see attachments being submitted in response to your message below. As a reminder, it appears that I do not currently have approval to gain entry into the SharePoint site sent to me. Thank you �b)(6); (b)(7)(C) Assistant Field Office Director ERO El Paso field Office 915-856r)(6)r (office) 915-726 "· "�' (cell) J(b)(6); (b)(7)(C) From: !lh\lR\· lh\l7\/C:\ Sent: Monday, June 04, 2018 10:07 AM To: l(b)(6); (b)(7)(C) Cc: I....________________________. Subject: HERNANDEZ Detainee Death Review Info Request Good morning AFOD Hernandez, As you know, our office will be reviewing the death of detainee HERNANDEZ who was in ICE custody at the Cibola County Correctional Center (CCCC) from May 17 - May 25, 2018, and who died on May 25, 2018. I will be the Team Lead for the review. Attached to this email is a request for information related to HERNANDEZ. We ask that your office provide the requested information by June 8, 2018 via SharePoint (the link is below). Please let me know who you would like to designate to upload and I will give them the appropriate permissions. If you have any questions about the request, please let me know. After we review the documents, we'll send a preliminary witness list of individuals we would like to interview during our onsite review. I'll also be following up with a request for information from San Luis and El Paso Processing, where the detainee was also held in custody before arrival at CCCC. 2020-ICLl-00006 981 Respectfully, l(b)(6); (b)(?)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 73 (b)(6); Cell: (202) 270 ( b )(?)(C l(b)(6); (b)(?)(C) 2020-ICLl-00006 982 ICCS CORRECT CARE SOLUTIONS Cibola County Correctional Center 2000 Cibola Loop Milan, New Mexico 87021 MEMORANDUM- Significant Event Notice -Death Date: To: May 25, 2018 (b)(6); (b)(?)(C) cc: I Health Services Administrator From: l(b)(6); (b)(?)(C) RE: HERNANDEZ, JEFFRY Cibola County Correctional Center Name: Hernandez, Jeffry A: 206 418 141 Country: Honduras DOB: 02/18/1985 DOA: 05/16/2018 Relevant Medical History/Diagnosis: The above Transgender Detainee anived at this facility last night from EPC where she was a less than 72 hour hold. On intake this detainee presented with fever, cough, significant weight loss over the last month, and reporting a history of being HIV and Hepatitis A positive. 05/25/2018 (0332) Patient pronounced deceased by two hospital physicians at 0332 MST. 05/25/2018 (0130) J(b)(6); (b)(?)(C) I NP from Lovelace Medical Center phoned Cibola Nurses Station and reported the patient is coding every 5 minutes and has minimal brain function at this time. 05/24/2018 (2300) At 1500 thoracentesis was done because patient was having difficulty breathing/sh01tness of breath and for diagnostics. Approximately 700cc of fluid was removed from one side and 900cc from other. No results yet on gram stains/cultures. At 1600 patient's oxygen saturation staiied falling (74%). Patient developed worsening tachypnea, SVT, and an 2020-ICLl-00006 983 elevated blood pressure. At approximately 1945 the decision was made to intubate, sedated, and place the patient on a ventilator. Patient also had a central line placed. At approximately 2210 the patent went into bradycardia and PEA- foiiunately the nurse and doctor were at bedside and chest compressions were started immediately. Multiple doses of epinephrine were provided and by 2216 she was resuscitated. Patient then went into SVT and received Adenosine (which was not effective) and then received Metoprolol which lowered her blood pressure. Vitals at 2330: Blood Pressure 114/48, Pulse 150 then at 2345 Blood Pressure 132/62, Pulse 165, 02 Saturation 93%. 05/24/2018 (1100) Received report from nursing on the above detainee. Vital signs at 1100 Blood Pressure 118/74, MAP 91, Pulse 104, Temp. 97.8, Resp. 18, 02 Sat 100% on 2 liters. Highest heart rate last night was 150 with a temperature of l 04.5 - Tylenol and cooling blanket were used to bring down temperature. Current Medication: IV Zosyn, Midodrine, IV fluids LR 100/hr, Tylenol 650mg every 6 hours by mouth, and Bactrim every 24 hours by mouth. Last dose of Tylenol at 0340 today. Patient is on regular diet receiving l 24grams of protein and ate breakfast this morning. Labs: WBC's 4.1, Neutrophils 70.3, Lymphocytes 17.5. Blood culture no growth yet, RPR-positive 1:32, TPA-Reactive, Toxoplasmosis-Negative, Malaria-Negative, No Parasites, Urine Culture 5/23/18 at 2212 - No bacteria/clear. Lumbar Puncture - Negative gram stain, no organisms, few WBC's - No opening pressure reading found in notes. No results back from axillary lymph node biopsy. Chest x-ray noted small bilateral pleural effusions in the lungs. Not on any respiratory therapy at this time. Nursing repoiis no diarrhea or skin lesions other than opening from lumbar puncture. At this this time her condition is critical. 05/23/2018 (2200) Unable to get earlier report. fb)(6); (b)(?)(C) I was able to speak with the nurse after evening shift change. Detainee has been febrile most of the day with high heart rate. Continues on oral antibiotics but may move back to IV antibiotics tomorrow. No results available from lymph node biopsy. 05/22/2018 (1800) Detainee remains in ICU, is stable, has been febrile most of the day, and without appetite. No results yet from lymph node biopsy. 05/22/2018 (0940) Detainee is stable post axillary lymph node removal. Spiked a fever last night of 39C (102.2F), is on oral Bactrim every 24 hours and once weekly injection of penicillin. Blood pressure has been lower and treatment at this time is IV Fluids (LR). Detainee remains in ICU. Nurse and attending will have a meeting later this morning to discuss course of care. 05/21/2018 (1545) Detainee had axillary lymph node removed today for biopsy, in recove1y at this time and stable. Nurse in recovery with patient reported detainee will be moving back up to ICU, but does not know if detainee will be back in negative pressure as AFB's returned were negative. 05/20/2018 (2230) !Cb)(6); (b)(?)(C) I received evening update. Patient is afeb1ile and no longer on medication to keep her blood pressure up. Needle biopsy is planned for Monday. 05/20/2018 (0840) 1Cb)(6); (b)(?)(C) I received morning update. Patient remains stable, no change from yesterday. 05/19/2018 (2130) j(b)(6);(b)(7)(C) I was able to call and get an evening update. Yesterday's CT of abdomen shows an enlarged spleen and peritoneal lymph nodes. l- 1 :·I� -t..·.. .-.-·-..•. ,.,_ . ·,� \. :·:f'�:· - CORRECT CARE SOlllr,o�s GENERAL NOTES Cibola County Correctional Center Facility Name.___ A206418141 Patient Name.___ HERNANDEZ, JEFFRY M Housing Location_ DOB: 02/18/1985 ARO: 05/16/2018 CCCC/MILAN. NM 87021 Date/Time Patient1Number_______ DOB._____..,....._____ Sex --\-:w,'11,9�\;) P N Notes Form 00039 / Authority: H-01 I Effective Date: 411/20091 Revision Date: 2/1812013 2020-ICLl-00006 989 · .-:i1:i . ,.,;.../ GENERAL NOTES Cibola County Correctional Center Facility Name_ A206418141 Patient Name_ HERNANDEZ, JEFFRY DOB: 02/18/1985 M Housing Location_ ARD: 05/16/2018 CCCC/MllAN, NM 87021 Date/Time Patient,Number_______ DOB ·. Sex ��&Aid (b)(6); (b)(7)(C} Notes --...---........�--=;-;.::=-' (b)(6); (b)(7)(C) CCS·CIBOLA b\/6l: /b\/7\/Cl CCS.CIBOLA Form 00039 I Authority: H-01I Effective Date: 41112009 l Revision Date: 2/18/2013 2020-ICLl-00006 990 PN A206418141 - CORRECT CARE lat.u,,a • • HERNANDEZ, JEFFRY DOB: 02/18/1985 ARD· 05/16/2018 C/M I LAN, �ryi 87021 _ Oate.S:S� l(b)(6); (b)(?)(C) ,, 'I( ,, �,1 :,'I I . _·(Iv _... ,, <>.1 --flll06 2020-ICLl- �) glf"l /{,,. /. /- . / q) ?fa ,J J'//. ,,./ f,.,.// 0 C tJ'-1 L, - ,I ,1_/ ; 00006 vv � b)(6); (b)(?)(C) 991 CCS-Cit.1via � �!CCS CORRECT CARE SOLUTIONS, INC. DUVQICIAN'S ORDERS - :- C O� s O L A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 10#: ------ ALLERGI S: _J/ l<=l/lc;...._______ :.........:.. Qll.TE PHYSICIAN·s ORDER � .....vl?·IY 111 /() 1/ I\ �y !J./ _/, \1\ I -,;, .., - l) f'I. L... � h'i OA,/, ' -cr i -I· bx.tu,� I i /: .;- I A � fl AJ,-, l r "-- " �f J./ /f�rl I,, . tJ ,-� (b)(6); (b)(7)(C) v I1 -u --t- .A 1 t� Ai ' L11. ! J-1£vt- I 0 / - /r/'77 l(b)(6); (b)(7)(C) g_ CCS-PLlf - /-'A .J ,I,. ;/, ./ '1.,9 X 1/ ,;,; ,:- I'/.,, _ / r· __./ 6) Medications: A,.,. . J // .......__ l(b)(6); (b)(7)(C) I 1/h\lR\· lh\/7\/C:\ 7) Vaccines: Hep A series Influenza (in season) Pneumonia Meningococcal (Meniclra) �� -To j(b)(6); (b)(?)(C) TX!l 1 (btmt!ily CCS·OO:,J I I l / � Hep B series TDaP dJnuL (@ � CCS-C1t,vlil -· - C,i_Ji-� iOA/RN CCS-CIBOLA l(b)(6); (b)(7)(C) n,viscdf/1� 2020-ICLl-00006 993 r..11n \ J-J� 00(5); 2020-ICLI-00006 994 A,cs f cilu: CORAC' I Gl.l>TIG • I A206418141 HERNANDEZ, JEFFRY DOB: 02/18/198S M ARD: 05/16/2018 CCCC/MILAN. NM 87021 �-lf-11 /ill/�� RESS.NOTES £"cu j l'A/,1,J L � l __ JI. ,.�i ,,, · i I An l(b)(6); (b)(7)(C) -� 'iL ,.ii::.. /L) - I;_ ,/DA- - , ,.;�-- 0 .,.. - • r.u ... , .... l -.· L J All A_/. • �; /J/ fl. J,._ ,_·L . ,..... �- A,£'. 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J 7,_,_ $"11. :J-Y A�n' �- · '·� 1 . t,_'MuT. / L ''f.i. tin � '_ 'flJ j f � Jy. j //· /1/11. L� - / -//-1 111 .dL -A• N,, !1.�I - �-h CIJ11 O" ( f J.Jr,-_. I l(b)(6); (b)(?)(C) , --- -- -- l(b)(6); (b)(?)(C) .... ,-...,-..rr,, _,...�L- - CCS•DW p;,,,,,.,,yGICS- u,se interpreter o . e., Y or (!j/ Name/Nurnb (b)(6); age hn er IL-..\f-,\f .r Pro�rr' History and Physical Health Assess� Social History History of Tobacco Use History of Alcohol Use History of Drug Use History of Withdrawals Prior Substance Abuse Treatment ffJN Amt I!. Last Use Last Use When: When: Y(W y n,y Y//{) y /'4 Mentaf Health Assessment I History of Mental Health Disorder Diagnosis: Mental Health Hospitalization{s): Where: History of Suicide Attempt/Ideation , nl111.b r I y /!i) I Y/f.U Qualified for: Regular Duty, Regular Housing, Food Senrice and Programs .OJ::° IS NOT qualtncd for the following: Alt"J-J 4,. /,7/� For How Long / ir;-, Amt/Tyoe: .::; __ ._ /.,,_L 7,,#/ , Type: What Drug: Where: {VJIN _/ )_ I When: I When/How: I' □ Assessment/Plan: IJ�oid,;,,_, �uJ..;_ D Follow-Up as needed via RNSC 0 Schedule wlth Chronic care Cllnlc(s): HTN _ Hepatitis _LOth er TG � �HIV //fv.f 1 �- ?��-.,,' A'/t, � ,4u-/� J;.._1 y--L t /1$// t..J,__ emla cardiac Neurology Diabetes _Syphllls _TST/INH _General Pulmonary /91. � �t, □ tab Order - See Provider Order Page □ Nurse BP Orders Needed - See Provider Order Page /� ft _ Gastroentero1ogy Mental Health - ER-,,._ ·, Education: ,0"' Nutrition, Exerdse and Weight Management counseling 12!' Risk reduction whlle detained: do not share personal items, no tattoos, wash �nds, refrain from sex �, er-'""MC?dlcal Access for routfne/urgent and emergent care 0 Other. � {fl( I Printed/Typed Name of Provider: j(b)(6); (b)(7)(C) ,...,...c, _r.·.nn,a I -�/'{ r Provider Signature: MD (b)(6); (b)(7)(C) l Pn'(Sloan Signature: Printed/Typed Name oflShyslclan: A206418141 HERNANDEZ, JEFFRY M 00B: 02/18/1985 ARO: OS/16/2018 87021 CCCC/MILAN, NM I I D # 2020-ICLl-00006 1005 I Oate/llme �-/J-/y' lo "'"" Date/Time 1 DOB 06/26/2018 10:14 From: 1#608 �.001/0:.?li V �'"- CIBOLA General Hospital. Inc. AM. -� - IUlli Kno-.-,.,.lt An·.• f:r•111>, NM 1170211 I 50.'i)l�i'-���6 • w11·w.db11!.,ho,11ir•l.,·t1m FAX COVER SHEET Health Information Management Department Phone: 505-287-5249 Fax: 505-287-5296 CONFIDENTIAL INFORMATION ATTACHED DATE: TO: J '5..)s .- \ t TIME: (b)(6), (b)(7)(C) FAX# q-.yy t\4_Q_______ REGARDING: _____ FROM:.____,t_l(b_)(6_);_(b_)(7_)(_C_) ------- !J_ � ----..---Ef?- '\2-e rc:Y\.of # OF PAGES INCLUDING COVER SHEET: •••• IF YOU HAVE RECEIVED THIS FAX IN ERROR, CALL US IMMEDIATELY AT 505-287-5249••• M fsslon Statement: To provide excellent hei1lthc1re that our com mu nlty I.! proud of by commlntng to: Service, Qu1lltv, People, Finan�, Growth VJS,or, Statement: To eam your trust and be the first choice for your healthcare CONFIDENTIALITY NOTICe: Thia fax, lncludlng any attachment is confldentlal and may contain protected patient Information th•t la confldenUal and prohibited from disclosure under HIPAA and •tate medical records confldentlallty laws, or prtvllegad Information protected by peer review privilege or other prlvllega. State and Federal Law prohibit• further disclosure of •uch Information without the apeclflc written authorization of the person lo Whom such Information pertains, or •• otherwise permitted by State and /or Federal Law. If you are not the Intended recipient of this fax, or have received It In error, pleaae contact the sender and destroy the tax. Thank you. 2020-ICLl-00006 1006 'ff "I 0 � Cibola General Hospital EMERGENCYFWWSHEETRECORD N ame: HERNANDEZ, JEFFRY A.ge: 33Y MR: 166116 Acct: 4499030 VITAL SIGNS TIME PAIN VTI'ALSICNS TIME 02SAT VITAL SIGNS TIME ENO-TIDAL CO2 -�- l(b)(6); I ('\ (b)�); I I l(b)(6); 89 (b)�); I (b)(6); 89 I l(b){6); l(b)(6);_ I lbl(6); I 89on I CROOM AIR) �)16); I C 0 OI .... N C ...� a, ..m .. .. - 0 0 a, OI 0 CD 'U 0 •..... 0 Name: HERNANDEZ, JEFFRY Age: 33Y MR: 166116 Acct: 4499030 Prepared: Fri May 18, 2018 12:35:00 by Interface Page: 3 2020-ICLl-00006 1007 0 Ill OI Cibola �neral Hospital . EMERGENCY FLOW SHEET RECORD Name: HERNANDEZ, JEFFRY A.ge: 33Y MR: Ui6116 ACct: 4499030 TIME BP MAP PULSE RESP TEMP PAIN 02SAT VITALSlGNS 5/17/2018 16:00 86162 70 13) 34 92 !i/l 7fl0l8 IS:45 91161 7S 127 30 5/1712018 15:30 87/61 92 90 (b)(6), I (b)(6); VJTALSIGNS TIME VITAL SIGNS VlTALSIGNS TIME (b)(6); (b)(7)(C) (b)(6); ,b){7){C) VITAL SIGNS (b)(6); TIME END-TIDAL CO2 'I TIME S/17/2018 14:01 TIME BP 88/64 VITALSlGNS TIME MAP VITAL SIGNS TIME PULSE VITAL SIGNS TIME RESP VITAL SIGNS TIME TEMP 72 27 (b)(6); I (b){6); 64 66 ... � -·,1,-,,\ 31 {b)(6); l C 82/57 (AUTOMATICl lbl(6\: Kb)(6); l 91 (b)�), S/l 7/20l8 11:59 l�b)��);_ 131 I 88 (b}(6);___ 26 l(b)��); ~ �b)�);_ �b)��);_ 134 I h\(6\· (b)(6); 80156 I ll4 5/17/2018 15:0) 102/65 77 116 (b)(6); b)(7){C 5/) 7/2018 13:47 l (b)(6); rh,n\lr I b\/6\· ,,_ .. k,... .. I 69 S/l7/20l8 U:IS 88/57 67 115 10 ., 137 I b)(6); I h\ln\· 18 I 104.9 lqc: 6 af 17 2020-ICLl-00006 1015 From; u #608 P.011/026 06/26/2018 10:19 v HERNt\NDEZ, JEFFRY DOB: 2/18/1985 MJJ WI/Ht: Med�: 166116 AcciNwn: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Nonnal chest radiograph. PROCEDURE: SUPINE AND UPRIGHT ABDOMEN RADIOGRAPH INDICATION: Cough, fever, headache, abdominal pain xS months COMPARISON: None FINDINGS: There is a nonobstNctive bowel gas pattern . Large quantity of small and large bowel gas is seen in the mid-upper abdomen. No free intraperiloneal air on en:ct view. The visualized oneow structures are unremarkable. IMPRESSION; No miiographic evidence of small bowel obstruction. Large quantity of small and lar&e bowel gas is seen in the mid upper abdomen. )(C.....)____ MD on 05/17/2018 (b.... INTERPRETED AND ELECTRONICALLY SIGNED BY1.,_ )(6.....),._. ; (b.....).... (7 ..,_ a103:34 PM RELEASED BY: 85 on 05/17/2018 1103:37 PM INTERPRETED and ELECTRONICALLY SIGNED BY:kh11R1 1h11111r.1 IMD Dictated Date: 5/17120 l 8 Transcribed Date: 511712018 l NAME: HERNANDEZ, JEFFRY Cibola General Hospital Exam N: 44990300001900 Exam Dt: 5/1712018 166116 Legallyaulhenticatedb)'llh\/n\ /h\/7)1(:\ 12018-05-1715:37:0I. CHEST2 VIEW ObserveDT: Thu May 17, 2018 14:01, CXR.2 CIBOLA GENERAL HOSPITAL Radiology Department GRANTS, NM 87020 1-505-287-5250 RADIOLOGY REPORT Pt Name: HERNANDEZ, JEFFRY Referring Physician: Jacket #: 166116 DOB: 2/1 8/l 98Sle.e b -"\/7'"'"\/'-"Cc.:...\ _______. lb:..:.:\l.,._ 6\"""' : /""" Pl Type: 0 Rm #: Sex; M Exam Dt: S/17/2018 MRN: 166116 PROCEDURE: PA AND LATERAL CHEST RADIOGRAPH JNDICATION: Cough, fever, headache, abdominal pain x5 months COMPARISON: None. FINDINGS: The lungs are well aerated. No foal consolidation, edema, pneumolhorax or pleural effusion. The cardiac silhouene is within nonnal limirs. The visualized osseous structures are unremarkable. IMPRESSION: Normal chest radiog.raph. PROCEDURE: SUPINE AND UPRIGHT ABDOMEN RADIOGRAPH JNDICATION: Cough, fever, headache, abdominal pain x5 months COMPARISON: None FINDINGS: There is a nonobstructivc bowel gas pattern . Large quantity of small end large bowel gas is seen in the mid-upper abdomen. No free intraperitone.1 air on erut view. The visualized osseous structures are unremarkable. IMPRESSION: No radiographic evidi:nce of small bowel obstruction. Large quanlity of small Pil&C: 7 of 17 2020-ICLl-00006 1016 From: ost26/201a ,0:10 u #608 P.0'12/02ti HERNANDEZ, JEFFRY DOB; 2/18/1985 MJ3 WI/Hl: M11dRcc: 166116 Acc:tNum: 44990.3-0 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD and large bowel gas is seen in tho mid upper abdomen. INTERPRETED AND ELECTRONICALLY SIONED BY: ll::(b l J.J:. )(6;..):..>;: (b:..c., l(:...,. 7)(..;;, C�) ____,!MD on 05/17/2018 al 03:34 PM RELEASED BY: BS on 0S/17/2018 at 03:37 PM IMD INTERPRETED and ELECTRONICALLY SIGNED BYlth\lR\ rh1m1r.1 Dictated Date: 5/17/2018 Transcribed Date: S/17/2018 NAME: HERNANDEZ, JEFFRY Cibola General Hospital EJl.am #: 44990300001800 Exam Dt: S/1712018 166116 Legally authc:nticaled byl(b)(6); (b)(7)(C) lG 2018-05-17 15:37:01 . LABORA TORY: MUIDl"tllltlll TROPONTN-1 Colloc:ti1:m OT: Thu M1v 17 20111 13:06 TROPI MPN!nmeal LlPASE CAllmlon OT: Thu Mav 17. 2018 ll:06 LIPASE. Kaull Uatb Rnite <1>.017 nlllmL 0.000--0.056 Ra11II VAIii Radl!e 511-H U/L '7l-39J Mtamttmeat Rna.lt Uallt Rlulte CK 14-L IUfL 39-301 Mea.111rcmm1 AMYLASE Collcc1icln OT: Tbu Mav 17 2011 13:06 AMYLASE Rnllfl U11JL'I Rall!EI' 114 IUIL 2S-115 CK TOTAL Collmion DT: TI,q Mav 17 2018 13;06 M•-remnl COMP METAB PANEL Collcclion OT: 11Ki M�v 17 2011 13:06 SODIUM POT llttltll Unka 130-L Dllll.01/L l.l mmolll. ll.9 nimol/L mmvl/L CL 98-L CA 12 7.5-L CO2 ANIONOAP OLUCOSE BUN:CREA RA TlO 105 BUN GFR mlldL RATIO DJr/dL o.s Bn.lRUBlN TOTAL TPROT 2.1- L ALBUMIN ALBUMIN GLOBULIN RATIO 0.S-L 4-IS l.4HO.:Z 74-106 10-20 IU/I.. 46-IJ6 (U/L IS-37 0.2-1.0 it/dL l.l-5.5 m11/dL GldL 7,0 100-108 21-31 0.7-J] IU/1. 17 22 135-145 l.6-S.O ma/dL 111Umin/t .1lm2 91 100 ALKALINE PHOSPHATASE ALT AST LACTIC ACID CollKtiva DT: Thu Mn· 17 201113:06 LA nttldL 26.S 26- H 1.0 CREATININE Mcuuraneat 111inal/L lb111!e RATIO lltn•lt Ualu Ra'llft 0,9 mmoUL 0.4-2.0 2020-ICLl-00006 1017 ->JO 14-67 6.7-8.2 1.1-1.1 061261201B 10;19 From: HERNANDEZ. JEFFRY DOB: 2/18/1985 M33 Wt/Ht: McdR.cc: 166I 16 Acc!Num: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Moau1remtt1t CBC AUTO DIFF Collcdion OT: Thu May 17 20 I 8 I J:06 #608 P.013/026 Rnult U11lh Rann SJi 10/JuL 10 GldL % ].6---9.6 4.64-6.00 12.0-16.0 ke�tbclow Pklll:ln cvllluation :,.l(l'CCI wil.b automo\ed count Pew unudtt� ccll1 'lln:IC!ll wee RBC 3.16- L 8.6-L HGB HCT ZS.3- L 80.1-L 27.2-L JJ.9 14.l- II 69-L J0.7-H 42.!il ll.4 22.9 0.2 MCV MCH MCHC RDW PLT MPV NE% LY% MO% EO% BA% 0.6 NEIi LY# MO# 1.9 2.4 1.l-H EO# BA&' 0.0 o.o Z7.6-ll.l n.o-14.8 11.6-1).7 150-450 7.4-10.4 P1[ 0/dJ. % 10 n. % % % % % 10 10 10 10 1.8-7.0 1.0-).4 G.1-0.8 0.0-0.J 0.CHI.I % 40---76 0-5 16---47 J-10 0---5.0 10 YES MANDIFF NEUT BA.ND LYMP MONO% EOS PLTEST lH8 81-91 n. 42 % % 5 ]5 18-H % % 0 DECREASE Mcaurnne111 PROTHROMBINTIME Collection DT: Thu M:,.v 17 2018 IJ,06 PROTHROMBIN TIME INR Tare1 R.n.e RHIIII U11fls R■lllrC 15.7-H ScnJgd.l U-14.5 1.l-H JNR 0.8-1.2 ·- ?rimaryUld �•ioo cif venous 2-) 2.5 lhrcimbosiJ J>revcnlicin ofR:CUrrcnt Y tnOIIS 1h «nnblws ].O B-3.S Pn: \fC!lioa or ancm, 1 tluvmboc:mbotism includina oatimt:i wlm. mcdwlical hean valves ).5 J.0 ••• New Prolhrombin TimD n:,fcn:ncc ran.tc cfT�tivc 2-1-18 ... INR INR z., - ltlmiu, 1-.. Pri ffl4N 1111d 1,eC<>n.dar,,, pre vcn tlon of vcno11S lhrombosi• 2 Pn:vcrn ion of n:curn:,,f -l V'CD0\11 thn,mboais 2.5 - J.S Pre Yeti lion of ancrial thrombocmbolism lncludina 2.5 J.O P,,c: ll of17 2020-ICLl-00006 1018 0S/26/2018 ,0:20 From: #608 P.014/026 V HERNANDEZ, JEFFRY DOB: 2/18/198S M33 Wt/Ht: MedRec: 166116 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD 1111thm1s w ltll mcdianicaJ hc4rt VilVi:S 2.5 - 3.S 3.0 ••• Nc:w Pnith...,..bin iunc n:lffcnco ran11.c dfcc,ivc 2-1-18 ... Mnsanmmt PARTIAL TiiROMBOTIMEColledion DT:Tb11Mav 17 2018 ll:S9 APTT •• Clboll, Genen,I Hosnital Labor.uiirv •• H marin ThniapCll1ia ranni: ror A P1T is 4 8-74 se conda. Retllll Uiiltl Rana,, 30.) Seconds 25-40 Ra11lf Units Ra11.11.c 449-H na/mL 0-lJO M euaninen t D.DIMER Co.tlcction DT: Th11 May 17 2018 IJ:S9 DDIMER The IMll.llfael\lrer ordlc 0-Dimcr DSH)' Ml approved II an,:iff'of 2JO nlllml. The, ma1111rKturer suta. lh.1.1 with !hill cut-off lhc, Ncptlvc PttwCIIVi: Va/ug ohhc lnl u 100% wtlh -�mcirv bcitween l6%-38'Yo. D-Dlmcr n:sulra iw rqioncd In nglmL. These 11ni111 com:5pond to na/mLof 0-Dimer Uzdlli fl>-DU). Mtuurnaml Rnoll U.nlb Ra"1!,c, MAONESIUM Collection DT: Thu May 17 2018 13:SII MAO 1.9 mR/dL 1.8-2.4 Mc,a,iunmHI Rnull U.nll, R■nH PHOSPHORUS Collection DT: Tiw May 17 2018 13:SII PHOS 4.0 mRldL 2.6-4.7 Mcu11nl'llffll URINALYSIS Collcctio11 DT·. Thu Mr1 17 2018 16:2S Sec, comment bdow F"" 1UP0111hous ccYSlall Catlidcr Urine MimJSCODlt a.nd UCOLOR UCLARITY SPECORAV UPII UOLU BILE KETONES UPROT UROBILE NITRtTe UBLOOD LEUKEST UWBC URBC UIJACT EPITH UCRYST CASTS \Mrut1rrmmt ic rcs•dts �le wed ror com:Jation Knall U111!1 YELLOW clear LOIS I.OOS-l.030 S-8 NEG NEO INEO NEG s NEOATIVE NEGATIVE NEOATIVE 2• I• NEOATIVE I• NEGATIVE 0-1 0-2 Rantt mltfdL 11.CJI. fHPF /HPF NEO NEO NEG 0-2 0-1 FEW RARE FEW 0 \Rnull /HPF /HPF ILPF RARE RARE -0 \U11fll P qc , 10 or 17 2020-ICLl-00006 1019 #608 P.D16/026 05/26/2018 10:20 From: V V KERNANDEZ, JEFFRY DOB; 2/18/198.5 M33 Wt/Ht: CIBOLA GENERAL HOSPITAL EMERGENCY RECORD MedRee: 166! 16 AcctNum: 4499030 C-REACTIVE PROTEIN Collcctitm OT; Thu Ma 17 lOI B I S:22 CRP MNA1R111ffll RAPID STIU:P OROUP A Col!cc:til,lll, DT: Thu Mav 17 201 8 17:06 ST.REPA All 11c•••1ve Srnn &CteCJU will be confirmed b v cu lwrc. 1>.0-0, 5.111-U ReHll Ran- Unlls NEGATIVE NEGATIVE CT: CTA CHESTWObscrvc OT: Thu May 17, 2018 14:56, CTACHEST ClBOLA GENER.AL HOSPITAL Radiology Department kb)(6): (b)(7)(C) 1-505-287-5250 ! RADIOLOGY REPORT Pt. Name: HERNANDEZ, JEFFRY Referring Physician: b... Jacket#: 166116 DOB: 2/18/1985 r..:akb:..::\l-'<\ _______. 6\""' : <..,. \/7"-'-\/'""'C;.:_ Pt Type: 0 Rm #: Sex: M Exam Dt: S/17/2018 MRN: 166116 PROCEDURE: CT ANGIOGRAPHY OF THE CHEST WITH CONTRAST INDICATION: 33-ye.ar-old male with elevated d-dimer and hypoxia TECHNJQUE: Multidetector CT imaging of the chest was performed following the in1ravenous administration of 100 rnL oflsovue-370. Coronal images were then created from the axial data. 3-D MIP refonnatted images were also obtained. One Of' moro oftbe following dose n:duclion lei:bniques were used: Automated exposure control. adjustment ofmA and/or kV a�rding to patient size, and/or use of iterative reconstruction technique. COMPARISON: None FINDINGS: Tb� i1 adequate opacification of the pulmonary arterial system. No filling defects are seeIJ to suggest pulmonary embolism. Numerous bilatend pulmonary micronodules are seen, aU measuring less than 6 mm. Multiple enlarged mediastinal and bilaleflll hilar lymph nodes are seen. A few such lymph nod1:s in the left hilar region conlain coarse calcifications. Although top differential consideration would include granulomatous disease such as sarooidosis, malignancy is to be excluded. Recommend EUS to fu:ilitate FNA r,f one of the abnormal mediastinal lymph nodes. No pulmonary parenchymal COl1$0lidatioo. No pleural or pericardia.I effusi0t1s. The visualized upper abdominal contents are unremarkable. The visualized osseous structures are unremarkable. IMPRESSION: No evidence of pulmonary embolism. Nwnerous bilateral puJmonary m.icronodules and multiple enlarged mediastinal/hilar lymph nodes arc seen. A few such lymph nodes in the left hilar region contain coarse calcifications. Although top differential consideration would include granulomatous disease such as sarcoidosis, malignancy is to be excluded. Recommend EUS to facilitate FNA of one of the abnormal mediastinal lymph DOdes. INTERPRETED AND ELECTRONICALLY SIGNED BY: kbl(6l: (bl(7l(Cl MD on 05/17/2018 u04:S2PM RELEASED BY: 8S on 0S/17/2018 at 05:08 PM INTERPRETED and ELECTRONICALLY SIGNED BY: [h\(fl\ lh\mff:\ MD Dictated Date: 5/1 71201 8 I I I'•: 11 or 17 2020-ICLl-00006 1020 06/26/2018 10:21 From: #608 P.016/026 HERNANDEZ, J'IFFRV DOB: 2/18/198S Mll WI/Ht: CIBOLA GENERAL HOSPITAL EMERGENCY RECORD MrdRe<:: 166116 ACCINum: 4'199030 Tnmsc:ribcd Date: 5/17/2018 NAME: HERNANDEZ. JEFFRY Cibola Gencntl Hospital Exam #: 44990300002000 Exam Dt: 5/ 11n.o 18 l 66116 !2018-05-17 17:08:01 . Legally authenticatc:d by l(b)(6); (b)(7)(C) LABORATORY· Mn, u l't1II NI I TYPE ANOSCR.E£N Colleciioa DT: Thu Mav 17.201116:17 PAnaq ABO GROUP AND lt.h PATIENT ANTIBODY SCREEN oPOSmVE NEClATIVf MEUunmeal ••PIO HlV I ANDl ADColl�iooDT: ThuM"" J7 20l8 U:21 IDVRAPlO R-iN! To lie 11e11 011110 Rc!CRnc:e Lab for .....,.flnNltion Th.is nmmt !a �fldmililal mnd i1 m,Ccctcd bv Fcd�I Law. Fe«ntl Ri,gu]atlon (0 C'FR, Put l) probibitl you 6-cnn makiua 1ny further dilclDIOff or it wilho111 the spcclnc wrincn COQKill of lllG pc110n lo whom it .......,... Rane Vllit1 KcsulC Ran1.c Raull Ualu REACTIVE NON REACTIVE wen or u othetwlae pc:nniai:d by regulation.a. A smctal awhorizalionfoc lhc n:1- of medical or Olllc, lnfonnation i1 NOT 11Vfficim1 for this .,.,,__ A raull rq,oncd u Reactive will be 1utoma1�1Uy C011flrmcd by Wman Blot. M"'11renit11I TSH lRD OENERATION Collccclon DT: Thu Mav 17 201117:S, TSH )RD OE.NERA TION lnf1111a rl-23 monw): 0.867--6.43 ulUlmL Chi� 12-ll Ymn,l:0.704-4.0J uJU/mL Adoleac=.1t tll-20 vmn): 0..516-4.13 ulUJmL >20 -: 0.3'11-l.740 uIU/mL Rt1■II U11fh ll■ne 2.5114 ··············································· •• .. AL.L TSH VALUES REPRESENT 3RD Of..NEAA TION TSH ··············································· ROS CONSTITUTIONAL: Hl1torian repor1s rever. EYES: Negative eye review of systems. ENT: Hhitorian reports 501'1! throat. CARDIO'JIASCUUR: Negative cardiovasc\llat review of sy11tcms. R£SPIIU.TORY: Hlslorlqn rcport1 cough. GI: Historian reports abdominal pain, vomiting. GENITOURINARY MALE: Negative genitourinary review of S)'ltcms, Tram gender. MUSCULOSKELETAL: Negative mW1culoskelctaJ review of systems. SKIN: Ncg■1ive skin review of systems. NEUROLOGIC: Negative neurologic review of systems. HEMOILYMPHATJC: NonnaJ hematologic.llymphatic system review. P,gc: 12 of 17 2020-ICLl-00006 1021 06/26/2018 10:21 u From: #608 r,_017/026 V HERNANDU. JEFFRY DOB: 2118/1985 MB WI/Ht: Med�: 166116 Ac:ctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD AUERG/CIIMMUNOLOG/C: HIV infection. PSYCHIATRIC: Trans gender. NOTES: Al\ systems reviewed, negative except as described above. PAST MEDICAL HISTORY MEDICAL HISTORY: No past medical history, Notes: Tramgender, Past mcdkal history Includes hJ1tory of bu man Immunodeficiency virus, not uader treatment. SURGICAL HISTORY MALE: Patient has oo surgical hJllory. PSYCHIATRIC HISTORY: No previous psychiatric history. SOCIAL HISTORY: Patient has no smoking history, Patient denies alcohol use, Patient denies drug use. PHYSICAL EXAM CONSTl1VTIONAL: Vital signs reviewed, Patient afebrilc, Pulle, tacbycardic. Blood prasun:, bypotraslvc. Respiratory rate nonnal, Patient appcarg non toxic, Patient 1ppears pain m:e, Patient alert and oriented to persoo, place and time. HEAD: Head exom normal, Head exam included findings of head atraumatic, normocephalic. EYES: Eye exam normal, Eye exam included findings of L")'elicb normal 10 inspection, Pupils equally round and reactive to light, Conjunctiva nonnal, Sciera normal. ENT: Ear exam nonna.l, Pharynx e,c:am normal, Mouth exam nonnal, Teeth with, Extensive dcintal decay. NECK: Neck exam normal, Neck cir.am includ� findings of normal range of motion, no cervical 1dcnopatby, no 1cnderncss. RESPIRA TORY CHEST: Respiratory and chest cnm nonnal, Rerpiratory exam included findin81 ofno respiratory distress, Breath sounds clear. CARDIOVASCULAR: Cardlo-vascular cum Included flndlngs of, rate tachycardlc, rhythm regular, Heart sounds normal. ABDOMEN MALE: Abdominal exam normal, Abdominal exam included ftndin� of abdomen nontcoder, Bowel 50unds nonuaJ, no di.$tension. BACK: Back exam nonnal, no tenderness, no costovertcbral anale tenderness. UPPER EXl'REMJTY: Upper exttcmiry exam normal, Range of motion normal, Motor Sffngth normal. LOWER EXTREMITY: Lower extremity exam nonnal, Moler strength oonnal, no edema, no calf tenderness. NEURO: Neuro cir.am nonnat, Glasgow coma scale IS, Neuro 1:xam findings include patient orienlcd to per1on, place and time, Speech normal, Gait normal, No i:;ross aculc rocal neuro deficit. SXJN: Skin exam nonnal, Skin eum included findings ofakin warm, dry. NOTES: Notes: b) patient remained mostly drr:ssed; limited cir.am. TRIAGE T PATIENT: AGE: 33, GENDER: nlllle, DOB: Mon Feb 18, 1985, TIME OF GREE : Thu May I 7, 2018 J I :51, MEDICAL RECORD NUMBER: 166116, ACCOUNT NUMBER: 4499030. NAME: Hernandez, Jeffry. NAME: Hernandez, Jeffiy. COMPLAINT: Dchydnltion. ADMISSION: UROENCY: LEVEL 3 URGENT, BED: ED .ROOM4. TRIAGE ASSESSMENT: Initial assessment perfonned, Patient mives to ED VIA corr�tional transport w/ c/o headache, cough, sore throat, hasn't fell well for 5 months. PROYIDERS: TRIAGE NURSE:tb)(6); (b)(7)(C) l HPIGENERAL History ofPre.snit Jllneu: Patient sent from prison ,yscem as • new arrival from immigrant Pqc: l)of17 2020-ICLl-00006 1022 05/26/2018 10:22 From; v t,608 P.01B/02E> V HERNANDEZ., JEFFRY DOB: 2/18/11185 M33 WI/HI: McdJloo: 166116 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD carboo from Honduru, who was found debydra1ed MSE aided comma with history of HIV infec1ion, untreated. Patient supposedly has a cough, fever. Pa1icnt stat&:S that he also has sore throat, worse on swallowing. Patient had OJl episode of vomiting yesterday. Patient slates that he has 11bdominal paiin on and off. Patient is trans, where is female hair do, and red nails. HISTORIAN: FadJlty doclor-'1 paperwork; patient;. LAB INTERPRETATION INTERPRETATION: CBC abnormal, Hemoglobin dttre111ed, Hematucrll decru,ed, Platelets decreased, Monocyte1 elevated; MCV and MCH decreased, Chimlstry abnormal, Sodium decreased, Chloride decreased, BUN elevated, Magnesium normal, Calcium decreued, CFR normal at 91; pboaphate normal;. Cardiac enzymes nonnal, Liver fuactlous abnormal, albumin decreased at 2.2;, PT abnormal, eleYated, PIT normal, Amylase normal, LlpHe abnormal. elevated, Urtnaly.b ab11ormaJ, posltln fo,- blllrubln, posttlve for proCeln, Few bacteria In thJs cath spedmen, C-rcactlve protein, elevated, D-dlmu, elevated, Lactate nonnal, Thyroid stimulating honnonc nonnal, CK normal al 14;. RADIOLOGY INTERPRETATION CHEST: Two view cbett x-ray; lungs are well aerated. No f01:al consolldaUon, no edema, no pneumotborax, ao pleural eff'uslon. Cardiac 1llhouet1e 11 wltbln normal llmlts. CT 1oi;Jography or the chest; no PE, Numerous bUaler■I pulmonary micro nodules are seen, all meaJuriag less than 6 mm. Muldple enlarged mediutlaal and bllatenl bllar lymph nodes are seen. A few such lymph nodes contain coarse calclDcallons. FNA I, recommended. No consolidation. No efTwlon. ABDOMEN: Two view abdomen x-ray; nonobstructin bowel gos pattern. Large quanllty of ,mall a.ad large bowel gas ls SH■ In the mid upper abdomen. No free lntraperttonul air on erect view. Vlsuallzed oneou, structures are unremarkable. INTERPRETER: Pn:limimuy review of x:-ntys by, Radiologist. Preliminary review of CT scans by, Radiologist. EKG INTERPRETATION 12 LEAD EKG INTERPRETATION.- 12 lcad EKG inlcrpreled by Emergency Department Physician, 12 lead EKG shows, slnu.1 tachyca,-dla, Rate (beat.s per minute): 12S, T wav1..-s normal, Axis oonnal, Other findings include:, RSR in VI and Vl; basdine wander; QTIQTC 329/475. DOCTOR NOTES NOTES: Patfeat reels better, Is hungry, wants lo eat. called UNMPab; no beds· Dhcuuc:d with (b)(6); (b)(7)(C) EVENTS lovelace:. MICU at lovel11cc downtown, accepts pt ID transfer;. I ATTENDING:KbJ(6); {b)[l)(C) saw petientat Thu May 17, 20 I 8 12:20. TRANSFER: Triage to Emergency BD .ROOM4. Removed from Emergency ED .ROOM4. NURSING ASSESSMENT: HEAD-TO-TOE CONSTl7VTIONAL: Complex assessment perfonncd, His1ory obaained from patient, Patient arrives am�latOJy, Gait 1,teady, Patient appears comfon■blc, Patient cooperative, Patient alert, Oriented to penon, place and time, Skin warm, Skin dry, Skin nonno.l in color, Mucous membranes pink, Mucous membranes moist, P11ticn1 is well-groomed. Sl(fN: Skin assessment findings include skin W11nn, Skin dry, Skin nonnal in color, Inspection 2020-ICLl-00006 1023 From; D6/26/2D18 10;22 V ,,.6oe P.0,01026 HERNANDEZ, JEPFRY DOB: 2/18/1985 M3J Wt/HI: MedRcc: 166116 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD findings include no abrasions, No Abcess, Inspection findings include no amp�talion, include no deformity, include no ecchymosis, include: No pressure ulcer lo the shoulder, include no preswre: ulcer to the elbow, Include no pressure ulcers to the hip, include no pressure ulcer lo the sacrum, include no pressure ulcer 10 !he heel, include no pressure ulcer, include no prenurc ulcer, include no signs of infection, include no signs of 1rauma, im:lude no swelling. NEURO: Pupils equally round and reactive lo light, Left pupil 2 mm in size, Righi pupil 2 mm in size, Able 10 close eyes, Face symmetrical, Speech normal, Hand grasps equal, Upper e11:tremi1y strength strong, no numbness to upper extremities, Lower cxtremily strength su--ong, Foot press equal, no numbness to I ewer e11:trcmilics. EYES.· Eye asseument findings include orbits normal, Eye lids normal, Conjunctiva normal, Sciera normal, Cornea clear, Iris normal. ENT.· Ear assessment findings include ear mmnal to inspection, Nasal assessment findings include nose normal to inspection, Sinuses nonno.l, Nasal mucosu normal, Moulh ond throal assessment findings include mouth inspection normal, Uvuh1 normal, Tonsils nonnal, Mucous membranes pink, and moist, Able to swallow, Speech normal, Associated with fever, Maximum temperature (degree F) 104,9, tympunlcally, Associated with decrcHed oral Intake. NECK: Neck asseasment findings include trachea mid line. BACK: Back assessment findings include no complaints of tenderness, Left dorsalis pedis pulse +3(easily pa.lpaled, considered normal), Right dorsalis pedis pulse +)(easily pal paled, considered normal). RESPIRATORY/CHEST: Reapiratory assessment findings include respiratory effort easy, Respirations regular, Conversing nonnally, oo signs of distress, Breath sounds clear, 10 bilaleral upper lobes, lo bilateral lower lobes. Neck and chest ex.um findings include trachea midline, Ches! e11:pansion equal, Chest movement symmetrical. CARDIOVASCULAR: Cardiovascular auessmeat findings include heart rate, tachycardk, Heart rhythm nonnal sinus, Heart sounds normal, Left radial pulse +](easily palpated, considered normal), Right radial pulse +](easily palpa1ed, considered normal), Left dorsalis pedis pulse +](easily palpated, considered nonnal), Right dorsalis pcdis pulse +J(easily palpated, considered nonnal). ABDOMEN: Abdomen assessment findings include abdomen symmetrical, Abdomen soft, Bowel sound normal, Associated with vomiting, history of vomiting, Vomiting yesterday. GENITOURINARY MALE: Male genitourinary ussessmmt findings include external genitalia nonnal, Scrotum nonnal, Testicles normal, Uncircumcised, Associated with dlsdiorgc, scant amount, of cheesy, white discharge, Associated with urinary complaints described H, difficulty urinating. LEFT UPPER EXTREMllY.· Left upper exlremily assessment findings include capillary refill less than 2 seconds, Skin color nonnal to hand, Skin temperature to hand wann, Dislal sensation Intact, Muscle tone normal, muscle strength S, no edema present, radial pulse is +3. RIGHT UPPER EXTREMITY: RJght upper extremily assessment findings include capillary refill Jess than 2 seconds, Skin color nonnal to hand, Skin temperature to hund wann, Distal sensation intact, Muscle tone normal, muscle strength S, no edema present, radial pulse is +3. LEFT LOWER EXTREMITY: Left lower extremity usessment findings include capillary refill less than 2 seconds, Skin color normal, Skin temperature warm, Diwal sensation intacl, Muscle tone nonnal, muscle slrength S, no edema present, dorsal is pedis pulse is +J. RIGHT LOWER EXTREMITY: Right lower extrcmily assessment findings include capillary refill less lhan 2 seconds, Skin color normal, Skin ttm1peralure wann, Distal sensation intact, Muscle tone normal, muscle strength S, no edema present, dorsalis pedis pulse is +3. PSYCH/SOCIAL: Psychiatric/social assessment findings include offecl nonnal, no complaint of visual hallU<:inations, no complaint of auditory hallucinaliona, no complaint of tactile hallucinations, no suicidal ideations. no homicidal idea1ions, no reported overdose. SAFETY: Side rails up, Curt/Stretcher in lowest posilion, Call light within reach, Hospital ID band on. Pnae: U uf 17 2020-ICLl-00006 1024 06/26/2018 10:23 From; u u 1160a p_o20102s HERNANDEZ, IEPFRY DOB: 2118119&5 Mll Wll'Ht: McdRcc: 166116 AcctN\lm: <1499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD NURSlr-lG PROCEDURE: EKG CHART et., PA71ENT IDENTIFIER: Patient's identity verified by p&rient staling name, hospital ID bracel EMS/police officer. d FOLLOW-UP: After procedure, EKO for incerpreiatlon given t ""b( :.Ll)(.=..6)"'--: ___. NURSING PROCEDURE: INTAKE AND OUTPUT /,..,,.AKE AND OUTPCil': Total Inlilke (ml}: 0ml. Urine output(ml): 750, Tolal Output (ml): 750ml, Grand Total; Output is grutcr than intake by 7S0mls. NURSING PROCEDURE: IV PATIENT /DENJTIFIER: Patient's identity verified by patient stating name, patient staling birth date, hospital ID lmc:eleL P11icnt'1 identity verified by patient stating name, palicnl stating birth dale, hospital ID bracelet. IV SfTE /: IV therapy indicated for hydration, medication administration. IV established, to the right foreann, using an 18 gauge catheter, in one attempt. IV site p�ppcd with Chloraprcp. Saline lock established, Flu.shed with nonnaJ saline (mis): I 0, Labs drawn at lime or placement, labeled in the presence oftbe patient and sent 10 lab, Blood culnares draWII a.I time of placement. labeled in lhe presence of tho patient and ,ent to lab. Flushed with normal saline (mls): I 0. IY SITE 2: IV therapy indicated for hydration. medication adminislration. IV established, to the left forearm, using an 18 gauge catheter, in one attempt, IV site prepped wi1h Alcohol, Saline lock established, Labs dn.wn at time of placement, labeled in the presence of the patiem and sent to lab. SAFETY: Side nils up, Cart/Slretcher in lowest position, C.all lighl within reach, Hospital ID band on. Side nails up, Cart/Stretcher in lowest position, CaU light within reach, HOSl)ital ID band on. NURSING PROCEDURE: NURSE NOTES NURSES NOTES: Nows: Patient b Dl•phoreth:, patient states she ba1 been dlapboreth: for I hour. SAFETY: Side rails up, Cart/Stretcher in lowest position, Call light within reach, Hospital ID band on. NURSING PROCEDURE: TRANSFER TRANSFER: Diagnosis: Septic shock, Accepting institutioo: Lovelace Downtown, Accepting !Notes: Room 7126, number for phy■ician: b)(6): (b)(7l(C) ererring physician:tb){6); report ls 50S-727 blf6t Diagnwiis: Sepsis, Acoepting institution: Lovelace Down town, Accepting physicianifilillO !Report called 10 receiving facili1y,l(bl(6): (bl(?)(C) (b)(6), efening ph)'lician: kbl(6), ty rova ed opportuni to answer questions, Bed assigned 7126. Reason for transfer nocd for spccializ.cd eve, Refening physician: l(b)(6); Tnan1po11ed by helicopter, accompanied by emergency medical services pcrsoMel, Report called to receiving !earlier no change, Summary of Care printed, Copy of patient !byl/bl/6\: facility, l(b)(6l: p per g record re ed for receivin facility, Patient consent for transfer signed. I I NURSING PROCEDURE: URINE COLLECTION P�TIENT IDENTIFIER: PatiCJJt's identity verified by palicnt stating name, patient stating birth dale, hospital ID bracelet. URJNE COLLECTION MALE: Urine collection indicated for patient unable to void, Coudc catheter inserted, using a 16 fr coude tatheter, in one attempt, urine yellow in color, and clear, Specimen collected, labeled in the presence of the patient and sent to lab, Specimen obtained for culture labeled in lhc presence orme patient and sent to lab. SAFETY: Side raib up, C11rt/S1retcher in lowest posilion, Call light within reach, Hospital ID band on. Past: 160(17 2020-1 C Ll-00006 1025 05/26/2018 10:23 From: #608 P.021/026 V HERNANDEl.. JEFFRY DOB: l/18/1 HS Mll WI/Ht; McdRec: 166! 16 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD VITAL SIGNS YITAL SIGNS: BP: 80/56, Pulse: 131, Resp: 31, 02 sat: 89, Time: S/17/2018 13:47. BP: 88/64, Pulse: 134. Resp: 27, 02 sat: 89, Tune: 5/17/2018 14:01. BP: 82/57 (AUTOMATIC), Pullie: 137, Resp: 18, Temp: 104.9 (TEMPORAL), 02 sat: 89 on (ROOM AIR), Time: S/17/2018 11:.59. BP: 86/62, Pulse: 131, Resp: 34, 02 sat: 92, Time: S/17/2018 16:00. BP: 91/67, Pul5e: 127, Resp: 30, 02 sat: 92, Time: Sil 7/2018 15:45. BP: 84/48, Pulse: 173, Resp: 18, 02 sat: 92, Time: S/17'2018 17:45. BP: 81/49, Resp: 17, Time: 5/17/2018 17:30. Temp: 101.l (TEMPORAL). BP: 86/59, Pulse: 107, Resp: 9, 02 sat: 96, Time: S/17/2018 18:15. BP: 91/66, Pulse: 106, Resp: 0, 02 sat: 95, Time: .5/17/2018 18:30. BP: 81/51, Pulse: 130, Resp: 18, 02 sa1: 96 on (ROOM AIR), Time: 5/17/2018 18:00. BP: 87/60, Pulae: 132, Resp: 36, 02 sat: 91, Time: S/17/2018 16:45. BP: 85/54, PulM: 110, Rup: 22, 02 sat: 91, Time: 5/17/2018 17:00. BP: 81/50, Pulse: 104, Resp: 20, 02 '8t: 92, Time: S/17/2018 17:15. BP: 90/60, Pulse: 131, Resp: 32, 02 s11: 92, Time: S/17/2018 16:30. BP; 86/6.5, Pulse: 122, Resp: 33, 02 aat 93, Time: 5/17/2018 115:IS. BP: 87161, Pulse: 114, 02 sat: 90, Time: S/17/2018 15:30. BP: 102/65, Pulse: I 16, Resp: 26, 02 sat: 91, Time: 5/17/2018 15:01. BP: 88157, Pulse: 135. Resp: 10, 02 sat: 88, Time: 5/17/2018 15:15. BP: 86/58, PulR: I 06, Resp: 6, 02 sat: l 00, Time: S/17/2018 I 9: IS. BP: 83/58, Pulse: 97, Resp: 11, 02 sat: 98, Time: SI 17/2018 19:30. BP: 83/S6, Pulse: 99, Resp: 0, 02 sat: 96, Time: S/17/2018 19:45. BP: 80/S2, Pul&c: 92, Resp: 17, 02 Ht: 96, Time: 5/17/2018 20:00. MEDICATION ADMINISTRATION SUMMARY Dr-«N.a,e az.i lhl'OfflYda inln.YeDCIUI •IOd111m cbloridc 0.4S % lnnvai11111 0 110di11111 chlo,;de 0.0 °� ianvcmowi -Mllloobea onl l\�phln ini calon •ICICllum dllorida 0.9 % intraYCTJ011, •sodium chloride 0,9 'M. lnl.nlva,aµ& •sodium chloride 0.9 % htlnlYCIIOUJ famalidiAc (PF) •sodium chloridl, 0.9 % lnlfDvcnom DD'R Ordered SOOm1r 1000 mL IOOOmL 650m• I lUGIII(sl JOOOmL IOOOmL lOOOmL 20-IOOOmt R.011lt IV Pi•.., BKII IV Flu.id IV fluid Orel IV pjHv Back IVFhaid IV Fluid IV Fluid IV PMSh IV Flu.id St11t1.11 Givai Given Given Ciin:n Given Gi� Given Given GiY<:11 Given Time I l;()S 5/17/2011 11:01 .S.,J 7'2011 11:06 '11712011 U:)() S/1712018 15;37 S/17/2011 U:J6 Sil 7fl011 l 5:J6 S/1712011 14:17 S/17/2018 13:J7 5117/2011 1);)7 5/171:1011 *AddiliOMI infonnuia11 available in�. Detailed n:c.xd avoilAblc in MC'llic411ioa Savitc MlCIIDl'I. ADMIN DIGITAL SIGNATURE: (b)(6); (b)(7)(C) (b)(6); (b)(7)(C) Key: r(6); (b )(7)(C) Pq<:: 17 of 17 2020-ICLl-00006 1026 06/26/2018 10:24 u From: V #608 P.022/026 Name: HERNANDEZ, JEFFRY Aac: 33Y 008: Feb 18, 1985 G"'-nder: M Wt; HI: MedRec: 166116 AcelNum: 4499030 Attending: )'6l: Primary RN: (bl(6): Bed: ED ED CIBOLA GENERAL HOSPITAL MEDICATION RECONCILIATION You were seen in the Emergency Department on: Thu May 17, 2018 KNOWN ALLERGIES No Known Drug Allergies MEDJCATlONS GIVEN WHILE IN THE EMERGENCY DEPARTMENT famotidinc (PF) 20 mg/2 mL - Dose: 20 milli8J'1lffl{s) Route: rv Pu$h sodium chlorido 0.9 o/o intravenous 0.9 % - Do,e: 1000 millilitcr(a) Route: JV Fluid Rocephin injection I aram - Dose: I gram(s) Route: JV Piggy Back &Odiwn chloride 0.9 % lntnsvenous 0.9 % - Dose: 1000 m.illiliter(s) Route: IV Fluid sodium chloride 0.9 % inttavcnous 0.9 ¾- Dose: 1000 millililcf(s) Route: JV Fluid sodium chloride 0.9 % intravenous 0,9 % - Dose: l000 milliliter(s) Route: IV Fluid acetaminophen oral 32S mg - Dose: 650 milligrun(s) Route: Oral az.ithromycin inlraVCJJOUI 500 mg - Dose: 500 milligram(s) Route: IV Piggy Back sodium chloride 0.45 % intravenous 0.45 % : (I 000 mL(s)J - Dose: I 000 milli\i1er(s) Route: IV Fluid sodium chloride 0.45 •1. intr.vll'tlous 0.45 % : [ l 000 mL(s)} - Dose: 1000 millililcJ(1) Route: IV Fluid HOME MEDICATIONS No Home Medications El1:e1ronically signed by MD I ofl 2020-ICLl-00006 1027 05/26/2018 10:24 From: V :{.-\·:�·/{;.,.. · .. : . · '· ·· .·: (QMPU'flD JPMQCRAfHf ccn PA'.D&NI OJIESJlO"fNNBJJCONDWfICQNSW . 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"41"! :1J ·-�(C,\, L ----�------J 2020-ICLl-00006 1028 #508 P.023/026 ., 4499030 5/17/20 8 2:05:55 PM CUIOIA a:z::KDU. � I lloffl 2/11/UU � ?eA>n 1� ----�111.4 ·-.......---·---------·----=--,,,-,,--:;.Udr.J, ciiidii .. ......................................................r• H Ice.: �125- Sll'lff q>e.rat,or. _ eeqwlJI•.••• , •••••..••..••. ,V co:,ple>< v/ � 11-R 1ft V t:dcuJ.u p� p y Plt RD' 11. V1 G•. _1-'-1>6-'!:..;.1 .,:;. 6 ______ MD, .-:!CV Love' 3'1Ce Q Pnw l C•• Q POltoe I Sh1nr. (b)(6); ------------1(b}(7)(C) Cibalo �I It.,_., 1--------- c... I ,.,,�� _, lil"H r,anr111r IIGC""' ( npl••io) P1c9 1 oU ,........,� 2020-ICLl-00006 1030 0-'5ii7/J6 6 11600 06/2612018 10:27 From: �,__,. ��:.:�· ;;;:.- .•,-·.-··.�-�":�: �;;:, ���; ._ ,;.;;-.,.�-:· :d:F--�-�:·.;�� ��·,, ..,�-� Jo"•':,=··: - .. ,, �-i...-..�,rit>_..;,-j,·..__,.:.._!ildftlDuh.�-"""°'7� 1-I,' • (', •• J, (f I •••A�' II '' f -._ l' I I tr 1 •; . •, ,,, ··.' 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FAX# i ·.Llz&-1 7., 2D\O TEL# ________ �---LN��____.ffi -.....· ----+--,l�®�-4 REGARDING: ____ FROM:l(b)(6); {b)(7){C) l HEALTii INfQBMATION TECHNICIAN # OF PAGES INCLUDING COVER SHEET: _______ •••• 1F YOU HAVE RECEIVED THIS FAX IN ERROR, CALL US IMMEDIATELY AT 505-287-5249°• Mlsslon Statement: To provide excellent healthcare that our community 1, proud of by committing to: service, Quality, People, Finance, Growth Vl9lon Statement: To earn your trust ind be the first choice for your healthcare CONFIDeNTJALITY NOTICEs This tax. lncludln9 any attachment Is conftdentlal and may contain protected patient lnform•tton that Is conftdentl■ I and prohlblt•d from dlsclosure under HIPAA and state medical nteonls conftdentlallty laws, or prlYlleged Information protected by peer review prlvllea• or other prlvllage. State and Federal Law prohibit• further dlecloaure of auch Information wltholllt tlle apeclfle written authorization of the person to Wllom such Information pertain•, or •• otherwt•• permitted by State and /or Federal Law. If yota are not th• Intended recipient of this tax, or have received It In error, pl••- contact the aender and destroy the fax. Thank you. q • 1i � s·�, l(b)(6), {b)(7){C) 2020-ICLl-00006 1032 I· , Cibola General Hospital EMERGENCY FLOW SHEET RECORD Name: HERNANDEZ, JEFFRY Age: 33Y MR: 166116 Acct: 4499030 VlTALSIGNS TIME BP MAP PULSE RF.SP 1'EMP PAIN _) 02SAT END-TIDAL CO2 VITAL SIGNS BP MAP PULSE RESP TEMP PAIN 02SAT b)(6\· l/b)C6l I S/17fl018 19:45 83/56 6S 99 .) BP MAP PULSE RESP 17 0 96 96 98 61 92 Kb)(6); t ,n"f""' I I l(b)(6); 1:,1111ml8 18:IS 86/59 68 107 9 96 l��l�h---1 l(b)(6), 5/17/2018 17:45 84148 60 173 18 %on (ROOM AIR) 92 I I b)(6), b\/6l: 5/17/2018 16:45 &1160 5/17/2018 17:00 8S/.54 64 110 22 I 5/11ll.018 18:00 81/51 61 130 18 132 36 b)(6); I 5/17/2018 16:30 5/17/2018 19:IS 86158 67 106 6 100 ( b )�� ; 0 l(bl(6l: I 17 tlb\/6): I 5/17/2018 17:15 8USO 60 104 20 (b)(6); I 5/17/2018 16:30 90/60 131 32 (b)(6); 91 92 91 l(b)(6), f VlTALSIGNS Name: HERNANDEZ,JEFFRY Age: 33Y Prepared: Fri May 18, 2018 08:42:02 b (bl(6l, (bl(ll(Cl 116 Acct: 4499030 Page: 1 .. 0 GI ... I 5/17/2018 16:IS 86165 72 122 33 o.cmi'vRALl END-TIDAL CO2 I - 5/17/2018 18:30 91166 74 106 95 S/17/2018 17:30 81/49 59 70 IOI.I I 92 fl) TEMP PAIN 02SAT I �h\/f\\ 5/l 7/2J.) 18 19:30 83158 66 97 II 5111no1s 20:00 80/52 F.ND-TIDAL CO2 VITAL SIGNS TIME I 93 ti) 0 •. 0 0 l,l Cl l,l ,,0 0 � 0 Cil N -::: '."".'iba--::-la---:::---e---- ==-os-p"""."ital-:--------------------------------------� � Gm ral H C , _ 6l .! EMERGENCY FLOW SHEET RECORD {. (bl _g Name: HERNANDEZ, JEFFRY Age: JJY MK: 166116 Acct! 4499030 TIME BP MAP PULSE RESP TEMP PAIN 02SAT ) VITAL SIGNS TIME END-TIDAL CO2 VITAL SIGNS TIME VITAL SIGNS VITAL SIGNS TIME TIME VITAL SIGNS TIME ) S/17/2018 16:00 86162 S/17/201& 15:45 91/67 15 70 131 34 127 30 92 92 (b)(6); (b)(7)(C) 5/17!2018 14:01 (b}�). - I 90 5/17/2018 13:47 (b)(6), S/17/2018 11:59 (b)(6); 80/S6 VITALSIGNS TIME (b)(6); ri� )(6 k. I VITAL SIGNS TIME 72 l(b)(6), /h\17\/('.\ PULSE VITALSIGNS TIME l1u (b)(6), VITAL SIGNS (b)(6); RESP TEMP /h1f7)1r.1 Tl l(b)(6), 111 l(b)({l), - 31 l(b)(6); /h\'7\/r\ I 5/17/2018 15:01 88 91 (b){6); 1/7)(C) /h1f7\lr1 I 102/65 "' � . 3 (7) -(? (C (,/) 77 116 26 I 1 I AUTOMATIC) l (b)(6); 66 I 137 �b)��k.l 18 �b)(6), 104.9 I ,,-'i£Mi'uRAU Name: HERNANDEZ, JEFFRY Age: 33Y MR: 166116 Acct: 4499030 Prepared: Fri May 18, 2018 08:42:02 b (b)(6), Page: 2 .. - 0 CII \b/(�):_ __ I 5/170018 15:IS 88/57 67 135 10 (b)(6); 82/S7 '-A I 69 114 (b)(6); �b)(7)(C) 88/64 MAP 87/61 (b)(6); (b)(7)(C � BP o... ,n 1,..., 5/l7nQll 1S:30 0 ' GI 0 at Ill w • !,I 0 r., ,, 0 0 la) 0 Ill � ... .. '11 0 0 Cibola �neraJ Hospital (b) EMERGENCY FLOW SHEET RECORD Name: HERNANDEZ,JEFFRY Age: 33Y MR: 166116 Acct: 4499030 VITAL SIGNS !�l�L. I PA.IN VITALSlGNS (b)(6); TIME TIME 02SAT VITALSIGNS ) I 89 (b)(6): :i � l(b)(6); fb)mic:) b)(6); I I 89 I I b)(6); TIME ), :I> l(b)(6); _. l (b)(6); l � ), � "'\ \i-. (b) 0 7)( .0 C) � en u u 89on lROOMAIR> (b)\�1: - r END-TIDAL CO2 0 a, = .. ._,.,. .... II) 0 a: ) 0 !I! a, l,O 0 Ill D Cil ,, ' 0 0 "'.... I Name: HERNANDEZ, JEFFRY Age: 33Y MR: 166116 Acct: 4499030 Prepared; Fri May 18, 2018 08:42:02 byl�?��?;rm Page: 3 2020-ICLl-00006 1035 0 Cal N 06/1B/2018 OB:53 From: V V CIBOLA GENERAL HOSPITAL EDPRINT ------------------- Patient Data Complaint: Dehydration Triage Time: Thu May 17, 2018 11 :59 Urgency: LEVFL 3 URGENT Bed:EDED Initial Vital Sips: S/17/2018 13:47 BP:80/56 MAP:64 T: Pain: 0393 P.00&/032 HERNANDEZ, JEFFRY DOB: 2/18119&5 MlJ Wt/Ht: McdR«: 166116 AcctNum: 4499030 ED AUendln : /b\/6\: /b\17l/C\ Primary RN: (b)(6); (b)(7)(C) R:31 P: 131 02 sat:89 End-Tidal CO2: ALLERGY (lt.:,�(F,)(6)�) No Known Dn,g er,,es KNOWN ALLERGIES No Known Dru1 Allergies CURRENT MEDICATIONS ci�(b)(6); No Home Medications TRIAGEm.. MIJ IT, Xiii 11� P�TIENT: AGE: 33, GENDER: male, DOB: Mon Feb 18, 1985, TIME OF GREET: Thu May 17, 2018 11 :SI, MEDICAL RECORD NUMBER: 166116. ACCOUNI' NUMBER: 4499030. m.uM1111, �II 11:SW'h\/fi\· ! I (12: l'l NAME: Hernandez. Jeffry.m,••1(b)(6 NAME: Hernandez, Jeffry.m:41 ), COMPLAINT: Dchydration.0111oMaJ 11.:zo1111:,•/b\/6\ ADMISSION: URO.ENCY: LEVEL 3 UROENT, BED: ED .ROOM4. mw ,..07 n. )1)1111:,9 I ™1fil TRIAGE ASSESSME1'll: Initial assessment performed, Patlent arrives to ED VIA correc1ional transport w/ c/o headache. cough. sore throat, hasn't felt well for S months. c1s:olrhvr;, I PROVIDERS: TRIAGE NURSE:!(b)(6); (b)(7)(C) l mtllM•t 17. lllll ll!StfiliiIBLJ NURSING ASSESSMENT: HEAD-TO-TOE riu:ofilillfil] CONSTITUTIONAL: Complex assessment perfonned, History obtained. from patient, Patient arrives ambulatory, Gait s1eady, Patient appears comrorr.ble, Palienl cooperative, Patient alert, Oriented to �m>n, place and time, Skin wann, Skin dry, Skin normal in color, Mucous membranes pink, Mucou.s membranes moist, Patient is well-groomed. SKIN: Skin assessment findings include skin warm, Skin dry, Skin nonnal in color, Insp«:tion finding& include no abraalons, No Abce.ss, rnspcction findings include no amputation, Include no deformity, include no ccchymosis, include: No pressure ulcer to the shoulder, include no pICSSure ulcer to the elbow, include no pressure ulcers to the hip, include no pressure ulcer to the sacrum, include no pressure ulcer to die heel, include no prcnure ulcer, include no pressure ulcer, include no ,igns or lnrection, include no sigru of trauma, Include no swelling. NEURO: Pupils equally round and reactive to light, Left pupil 2 mm In size, Right pupil 2 mm in size. Able lo close eyes. Face symmetrical. Speech nonnal, !-land grasps etem-Thu May 17, 2018 17:45,os�llh\lRll TSH: Ordered b : (b)(6); (b)(7)(C) Ordered fi )( ; {b)(7 C) Status: Done by: System - Thu May I 7, 2018 18: I 6. c I J,"6!(b )(6)! EKG INTERPRETATIONo•:J� 12 lcad EKG interpreted by Emergency Department Physician, 12 lud EKG shows, sinus tachycardia, Ra1e (beats per minute): 125, T waves normal, AAis normal, Other findings include:, RSR ln Vl and V1; baseline wander; QT/QTC 329/475. 12 LEAD EKG IWTERPRETATION: LAB INTERPRETATION I ll:SJIZiillfil] INTERPREl'ATION: CBC abnormal, Hemoglobin d�reued. Hematocrit decreased, Platelets decreased, Monocytcs elevated; MCV and MCH decreased, Chemistry ■baonnal, Sodium denused, Chloride dee�. BUN elevated, Magnesium normal, Calcium decreased, GFR normal at 91; phosphate normal;, Cardiac enzymes normal, Liver funct.lona abnormal, albumJn decreased at 2.1;, PT abnormal, elevated, PIT normal, Amylase nonnaJ, Lipase ■ bnonnal, el�vated, Urlnal)'Sls abnormal, posltln for bWrubln, positive for prol.eln, Few bacteria hi this cath 11pedmen, C-reactlve protein, elevated, D-dlmer, elevated, Lactate normal, Thyroid stimulating hormone normal, CK normal at 14;. RADIOWGY INTERPRETATION !(b)(6); (b)(7)(C) c(;S-C i L:iola J>agt: 5 Df 17 Prepared: Fri May 18, 'lOll 01:42 by tbl/6\:1 2020-ICLl-00006 1040 ! M0 #393 P.o,o,oa2 From: HERNANDEZ, JEFFRY DOB: 2/IB/1985 M33 Wt/1-11: MedRcc:: 166116 A<:etNum: 4499030 CIBOLA GENERAL HOSPITAL ED PRINT CHEST: Two view chest x-ray; lunp are well aerakd. No focal consolidation, no edema, no pneumothorax, no pleural dl'wlon. Cardiac sUhouette ls within normal limits. m"'*bl/6) I CT angiography of the chest; no PE. Numerous bilateral pulmonary micro nodules are seen. all measuring less than 6 mm. Multiple enlarged mediasEinal and bilateral hHar lymph nodes are seen. A few such lympb nodes contain coarR caldficatlons. FNA ls recommended, No consolidation. No effaslon.m,.,�(b)(6): ABDOMEN: Two view abdomen x-ray; nonobstructive bowel gas pattern. Large quantity of small and large bowel gu b seen In the mid upper abdomen. No free Jntraperltoneal air on erect view, Visualized osseam structures are unremarkable. (IJ:4-li'h""• INTERPRETER: Preliminary review of it-rays by, Radiologist.u,,.1cb)(6); Preliminary review or CT scans by, Radiologist. u1:n€ill) I I RESULTS RADIOLOGY: ABDOMEN 2 VIEW Observe OT: Thu May 17, 2018 14:01, ABD2 CIBOLA GENERAL HOS PITAL Radiology Department GRANTS, NM 87020 1-.505-287-5250 RADIOLOGY REPORT Pt. Name: HERNANDEZ, JEFFRY Referring Physician: f7___ \/C___l_____Jacket #: 1661 I 6 DOB: 2/ 18/19B5 l=I� Mmainmen1 AMYLASE Colh:cilon DT: Tb11 M11,v 17 2011 I J:06 AMYL.ASE Mtu11ranenl COMP METAB PANEL Collcctkln DT: i'hll MiiY I 7 2018 1 l :06 SODIUM POT CL CO2 ANIONCl'AP CA OWCOSE DUN:CREA RATIO Result Units Rann 130-L mmol/L mmol/L mmol/L ounol/L mmol/L 135-145 J.6-.5.0 3.8 98-L 23.9 12 mw4L 7.5-L lnu/dL RATIO mlfld.L \� 26.S BUN Z6-H CREATININE OFR ALKALINB PHOSPHATASE ALT AST BIURUBIN TOTAL TPROT ALBUMIN ALBUMIN GLOBULIN RATIO mr/dt. 1.0 91 100 17 22 O.S 7.0 2.1-L mUminll .7lm2 IUIL IU'1.. IUIL mi!ldL GldL r/dl. RATIO G.5-L 100-108 21-31 4-1' 8.4-10.2 74-106 10-20 0.7-1.3 ->30 46-116 1�7 1.5-37 0.2-1.0 6.7-8.2 J.2-5.S 1.1-1.8 (ll:-� Mll:lllUrttntnl LAcnC ACID Collealon DT: Thu Mav 17 2018 ll:06 LA Rfflllt Unlti!I Ran.11e 0.9 mmoUL 0.4-2.0 Mewiurau:nt Remit Units RIIZln wee RBC .5.6 J.16- L 8.6-L 10 10/3 11L J.6--9.6 4.1$4-6.00 CBC Atrro DJPF Collection OT: lln.i May 17 201 II I 3:06 See comntCn1 hdO'# P1 IZlllCI cvalllllllaD aiuea with 11\ilomalCd C0\1111 Few smudae cells im:Knl HGB HCT MCV MCR 2!.J-L 80.1-L 27,2-L MCHC ]J,9 RDW 14.l-H 69-L 10.7-H 42.9 33. 4 22.9 0.2 PLT MPV NE'lo L.Y'lo MO'ili EQ'I, BA'lf, 0.6 G/dL � rt oa " ... 0/dL 10 IL .... 11,0-16.0 36-48 81-P8 27.6-JJ.J Jl.0-34.8 11,6-13.7 150-450 7.4-10.4 'ii, 'If, Pff,pvcd; Frl May 18, 2011108:42 by !(b )(6)! ,; J 'I ·/fo,1 I llh)lfl)· /h)/7)(<,) 1t1ul a CC S-C Pace: Sor 11 2020-1 C Ll-00006 1043 1°·,,'; D 0&1,e120,a oa:&7 From: HERNANDEZ, JEFFRY DOB: 2/18/1985 Mll Wt/HI: MedRec: 166116 Ac:ctNum: 4499030 CIBOLA GENERAL HOSPITAL ED PRINT NB# LY# 2.4 l.!l EOlf BA# MANDIFP NE\TT BAND LYMP 0.0 0.0 YK'i 42 MOI MONO'I. BOS PLT� 10 10 JO 1.J-H ID 10 .. s 'ii, 35 111-H 0 DECREASE !IJ>4Jlih\iml MIIQllll"ffllml PRO'THROMBIN TIME Collection OT; Thu Mav 17 2018 I 3:06 PROTHROMBIN TIME INR #393 P.013/032 'I, '91. � 1.8-7.0 1.0-3.4 O.H.I 0.0--0.3 0.0--0.1 40-715 0-S 16-47 2-JO 0-.5.0 Result Vnll.11 Rarlat 15.7-H Seconds 9,8-14.5 1.J-H INR 0.8-1.l Ruu1c T•-ct Pri ... and scc:on d•~ nn,vl!1\llon of venous •~ 2-3 2.5 �va11lonofreculT'Cnl. vcnow thrombosis 2.5- ).5 3.0 PnM:ntlon or ancrial lhmmboembolisiu lnclwiin,: 11111lcnts wllh mldllullcal valves 2.3 - ),.5 3.0 ••• New Prolhrombln TllflO rcrcrc:ncc nnac cffoc1ivo 2-1-18 ••• INR INR T.,,_. R.a.nac Prlnwv and nn,venuonofvmcw 2-) tluuinbosls 2.5 Pf'cYllllltion Of rteum:nl VCIIOm thrvmbosis 2.5- l.5 J.O Pre Yffl rion of artcrla I lhrom bocm bolli m Inc I udin1. Dlltlents wi1h mechanical heart valves 2.S-3.S J.O •u New Prothrombi.n Time �fcrmco ranac crreictive 2-1-18 •u !Mlfflbosis nun !14•� Mcauremeat PARTIAL mRDMBO TIME Collmion DT: Thu Mav 17 2011 13:S!l AP'IT u Ciba la Ocnc:nll Hosnlt41 Lllboral~ •• Hmarin ,;= ·c ranac !or AP1T Is 41-74 scccnds. MCIIIUreznml D.DIMER COUectlon D1: Thu Mav 17. 2011113:59 DDIMER � ITIAnUf� or lbc D-Dimcr Qllay hu approved a c:ut--olf of Rautt Untts RM11:e 30.J Seamds lS--40 Rauh tJnltt Rann 44!1-11 11Plml 0-230 2JOn&lrnl. The ma.nufac:1\1rer sia\CS !Ml with lhis cul-off !he Ncg111l11c Pre:Uctlve Value orlhc test u JOO'il, wilh !""cinchY between 36'lf>-JH,. D-Dimer rcsul� arc reporccd In Dg/mL. These unia. com:spond \0 Pnipvcd: Fri MBy 18. 2-01 a oa,42 by� 2020-ICLl-00006 1044 S l '/·/}'llli[] !(t;,V6l)b}/7l/C} ccS-Cillola 1 1D 1 "' o&/1812018 oe:&a From: V CIBOLA GENERAL HOSPITAL EDPRINT #393 P.D14/032 HERNANDEZ, JEFFRY DOB: 2/1811985 M33 Wt/Ht MedRcc: 166116 Ac�um: 4499030 oJ mL rur/ hMifflQ \Jnits (D-DU). (14� Me.uuRmaat RCIUII l/nlll JlJul•e MAO l.9 111a/dt. 1.1-2.4 MACNESIUM Colh:�tlcn CT: 11111 M■v 17 2018 IJ:,9 ( 14 � M-R!llftlt PHOSPHORUS Col1C1:don DT: Th11 May 17 201S I J;S9 PHOS Raul& 4.0 ( IUl1Tti\'i611 Result M-ft'D'ltml URINALYSIS C.ollectlon DT: Th11 M11v 17 2011115:25 See comment bc:Jow f'ew a.momtilJIIS �tab Callida' Urine ·e iaulu �viewed c:orrelm1u;in Mtm11CDDIC IUld ;;-_ UCOLOR rllf Ruire lnwdL 2.6..4f.7 Vntu Ruff YELLOW clur UCU.RJTY SPl!CORAV 1.005-1.0JO LOIS .s UPH NEOATIVE N&JATIVE NEOATIYE 2♦ UOl.U BILB KETONBS UPROT UROBIU! NITRrTB I+ L.EUKEST UWBC URBC U8ACT NEOATIVE I+ NEOATIYE 0--1 0-2 PBW CASTS FEW 0 UBLOOD RARE BPmt UCRYST (I ...J.(bl(6l. I Measuranmt C-R.EACJlVEPROTBIN Conaaioll DT: Thu May 17. 2019 IS:2? CRP {17:m/h\/R\I M&lllUellmt Ualb RAPID STREP GROUP A Collection DT: Thu Mav 17 2018 17:06 STRBPA AU ne11.111vc sun l4;IWnl will be confllffled by c:ul111n1. 5-1 NEO NOO Nf!O mJ/dl. nca /HPP IHPP IHPP IHPF fl.Pf NF.O NEC NEO NF.O 0-2 0-1 RARE RAJU! -0 Ra\,Jt Units Ranae 5.8-H asaldL 0,0-0.!I Rault Uftlb Rutt NOOATIVE NEOATIVE CT: CTA CHEST W Observe DT: Thu May 17, 2018 J 4:56, CTACHEST CIBOLA OENERAL HOSPITAL Radiology Department GRANTS, NM 87020 1-SOS-281-5250 RADIOLOGY REPORT Pt. Name: HERNANDEZ. JEFFRY Referring Physician: Jackel#: 166116 DOB: 2118/198S !l!.!: (b:.!1. )(6�)·�(b�l(c:.. 7l�(C;:.:_l ______. Pt Type: 0 Rm #: Sex; M 5 .:; �-1���>,l tviD Mary Bir.'3ong CCS-Ciboia &am Dt: 5/17/2018 MRN: 166116 Page: 10 or 17 2020-ICLl-00006 1045 06/18/2018 08:68 From: V HERNANDEZ. JEFFRY DOB: 2/18/198, M33 WI/Ht: MedRcc: 166116 AcctNum; 4499030 CIBOLA GENERAL HOSPITAL ED PRINT PROCEDURE: CT ANGIOORAPHY OF TiiE CHEST WITH CONTRAST INDICATION: 33-year�ld male with elevated d-dimer and hypoxia TECHNIQUE: Multidelector er imaging of the chest wu pecfonned following the intravenous administration or 100 mL of lsovue-370. Coronal images were then created from lhe uial data. 3-D MIP reformatted images were also obtained. One or more of the following dose reduction techniques were used: Automated exposure control, adjustment of mA and/or kV according lo patient size, and/or we or iterative reconstruction technique. COMPARISON: None FINDINGS: There is adequate opacitication of the pulmonary arterial system. No filling defcets arc seen 10 suggest pulmonary embolism. Numerous bilateral pulmonary micronodules arc seen, all measuring less than 6 mm. Multiple enlarged mediastinal and bilateral hilar lymph nodes are seen. A few such lymph nodes in the lef\ hilar region contain coarse calcifications. Although top differential consideration WQuld include granulomatous disease such a.s san:oid05is, malignancy is to be excluded. Recommend EUS to facililate FNA of one of 1he abnormal mediastinal lymph nodes. No pulmonary parenchymal consolidation. No pleural or pericardia! effusions. The visualized upper abdominal contents are unremarkable. The visualized osseous atruc1ures arc unremarkable. IMPRESSION: No evidence of pulmonary embolism. Numerous bilateral pulmonary mic:ronodulcs and multiple enlarged mcdiastinal/bilar lymph nodes are seen. A few such lymph nodes in the left hilar region comain coarse calcificatioru. Although top differential considcnation would include granulomatous disease such as san:oidosis, malignancy is to be excluded. Recommend EUS l0 facilitate FNA of one of the abnormal medias1inal lymph nodes . .INTERPRETED AND ELECTRONICALLY SIGNED BY: kbl(6l: (b\(7)/Cl at04:52PM RELEASED BY: BS on 05/17/2018 at 05:08 PM INIBRPRETED and ELF.CTRONICALL.Y SIGNED BY: Kb)(6); (b)(7)(C) Dictaled Date: 5/ I 7/20 l 8 Transcribed Date: SI 1712018 TYPE AND SCREEN Collcct!cn DT: Thu May 11 20111 16: 17 PATIJ!NT ABO GROUP AND Rh PATIBN:T' AmlBODY SCREl!N .e11,� \Jlllll RIIUlt M-IYfflflll I MD on 05/17/2018 I MD NAME: HERNANDEZ. JEFFRY Cibola General Hospital Exam#: 44990300002000Eum 01: 5117/2018166116 Legally aulhentlcaled bykbl(6l (b)(7)(Cl IO 2018-0S-17 17:08:01 LA BORA TORY: c 11:211fh\iirn •3&3 P.016/032 Ranft OPOSmVE NEOATIVE 111,.� Meawr"Ullfflt RAPID HIV I ANO 2 AB Colkll:tian OT: Thu M11Y 17 2011 I S:21 HIVRAPID R� Result Unll.l REACTIVE NON REACTrvE Ra,,.,., To be 1crn DUI 10 Rcrc:rence Lab for conflrm11llon Pn:pand: Prt M11y IIS, 20110¥:4Z � Page: II or 17 2020-ICLl-00006 1046 06/"18/20"18 08;&8 V V CIBOLA GENERAL HOSPITAL EDPRINT •393 P.016/032 HERNANDEZ, JEFFRY DOB: VIS/1985 M3J Wt/Ht MedRcc: 166116 Ace1Num: 4499030 Thia rcoott iJ mnfldcntial and b llnli«tcd bY �I uiw. Fedenll ftl:1u.l1tlOl'I (42 CPR, Pan 2) prohlbiu you Crom making any funhc:r dilcloslll'I! of il wllhout !he spectnc wriucn COl\k:nl of tha. pc:n011 10 whom ii -..1n, or u ol.bi:rwlse pc:mllltCd by such rcgula.doru. A ,ena-al W1horizacion for die aelc.uc of mcdlcv or od\c,- Ln!orma1ion u NOT u1fficiml for lhia numose. A ravll rq,or1cd u Rcactivs will be 1utomwc1Hy eonf1mt.cd by Wcs\Cm Blot. (18:1� Mauuraneat TSH JRO OE!NBRA TJON Collccllon OT: Thu M«-Y 17 20 I B J 7:SS TSH 3RD GENERATION lnf11.nts f 1-2) morulll): 0.167�.4] uJU/mL Ouldrcn (2-12 Yarsl: 0.704-4.01 uJU/mL AdolOS0CIIII ( I J-20 wan}: 0.S 16-4.13 ulU/ml. >ZOwan; 0.3�11-3.740ulU/mL Unlt.t Result RanICI 2.514 ••••••••••••••••••••••••••••••••••••••••••••••• •• ALL TSH VALUES REPRESENT JRD OEN ERA TION TSH ••••••••••••••••••••••••••••••••••••••••••••••• •• MEDICATION ADMINISTRATION SUMMARY Dn.i11 Name u.ldironwcin ianvenom -Sodium c:llloridc O 4.1 41, ln1rncl\ow � odl um chloride 0,4 5 'I, UUl'IVCl\0111 DoHOnlend soo ffll! 1000ml. IOOOmL accwnino� cnl 6SOlll• �In ln_icc,ion •ll>d lum dlloridc 0. 9 'I, lrur.vr:l'IOUI •so,dlwn dllorido 0.9 • lo1nw:r1oua -sodium ,hloridc 0.9 ,& lnuavonow famotfdinc (PF) •sodium dtloridc 0,9 .. inlnVCI\O\IS I .1Ta.mhl 1000 mL IOOOmL. 1000ml. 20ml IOOOmL Kou.le IV PluvBack IV Fluid rv Pluid OraJ JV Pinv BIICk IV fluid IV Pluid IV Fluid rv Push IV Auld S&lltllS Olvcn OIYffl Oivcn Oivai OIYen Oiven Otvcn OiYc:n Gi� Olvcn T1D!.c IS:08 .5117n018 18:08 1117/2018 11:06 SI 1712018 IS:50 !l/17'2018 15;37 '117/2018 J�:36 5/17n018 IS:)6 .5117/2018 1<1: 11 s111no1 ll:37 S/1712018 13:J7 5117nOJ8 s •A.ddhlonAI infomvollon av■ilable In notes, Dcualled �otd available: in Medlc:•tion Service sa:clon. MEDICATION SERVICE acetaminophen oral: Order: acetaminophen oral 325 mg - Dose: 650 mg Route: Oral ! Ordered by: l i,ur�nous: Order: sodium chloride 0.9 � intravenous 0,9 9& Dose: 1000 mL Route: IV Fluid Notes: l 000 cc per bour Ordered by: (b)(6); (b)(7)(C) Entered by: Thu May 17, 2018 12:26 Ackn.owledged by: I l/6l:/ l/7\(C\ u May 17, 2018 13:08 Documented as given byl1b)(6l: lblr7\/C\ rI'hu May 17, 2018 13:37 Patient, Medication, Dose. Route, Schedule \lerified prior to administration., IV SITE# 1 (V fluids Cllablishcd, rv SITE #1 ht bag hung, amount I Liter, IV srrn #I bolU5 of 1000 ml C5tablished, IV SITE #1 Rate of bolus, wide open. via primary tubing, Connections checked prior to administration, Line traced prior to administration, Catbetcr placement confirmed via flush prior 10 adminls111rion. IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confinned prior to administration, Patient advised of actions and side-effects prior to adminisll'l.tlon, Allergies confirmed and medications reviewed prior to administration, Patient in p01ition comfort. Side rails up. Cart in lo�st position. : Follow Up: No signs or symptoms of allergic reaction noted. _IV SITE #I;_, IV fluid infusion discon1inucd, on Thu May 17, 2018 14:40, Total amount infused: 1000, Ad..,iied not to ambulate withoul assistance, Patient In po&ition of comfort. Side rails up, Cart in lowest position, Family at bedside. 11•.� I or or sodium chloride 0.9 'lo inlravenous: Order; sodium chloride 0.9 % intravenow 0.9 '.lb - Dose: 1000 mL Route: IV Pluid Note.I: 1000 cc per hour, 2nd IV silt Ordered by: (b)(6); (b)(7)(C) Enreied by: Thu May 17, 2018 13:S4 k g y b iven b : )(6): (b)(7)(C) !Thu May 17, 2018 14: 17 Documented as Patient, Medication, Dose, Route, Schedule verified prior 10 administration., IV SITE #I IV fluids established, JV SITB #I 2nd bag hung, amount I Liter, JV SITE #I bolus of 1000 ml established, rv SITE # I Rate of bolus, wide open, via primary tubing, Connections checked prior to administration, Line llaccd prior to administration. Catheter placement confitmed via flush. prior 10 administration, IV site wilhout signs or symptoms or infiltration dw-ing medication administration. No swelling during Prepared: Prl May II. 2018 08:42 � f·r1-1� kb)(6); (bl(7)(Cl c,;s .c i t.io la �11c:: 14 of 17 2020-ICLl-00006 1049 I r•.m 0&11e120,a oe:oo u Frotn: •393 P.0'19/032 V KERNANDEZ, JEFFRY DOB: 2/18/1985 M33 Wt/Ht: MedRec: 166116 AcctNurn: 4499030 CIBOLA GENERAL HOSPITAL EDPRINT administration. No drainage during adminislration. IV flushed after 11d�inis1rat�on, Corr�t patient. lime route dose and medication confirmed prior 10 administration, Pat1enl advised of acuons and sidc.:.Crrect's prior to adminislration, Allergies confirmed and med\calions reviewed prior l0 admlnis1ra1ion. Patient in position or comfort, Side rails up, Cart in lowest position: . : Follow Up : No signs or symptoms or allergic reaction noted. _IV SITE# 1 :_, IV flu1d inf\mon discontinued, on Thu May 17, 2018 15: 17, Total amount infused: 1000. Advised not to ambulate without assistance. Parie.nt in position of comfort. Side rails up. Cart in lowesl position. us,., lth)(fn· I 1odium chloride 0.9 9& lnmwenous: Order: sodium chloride 0.9 % inuavenous 0.9 % Dose: 1000 mL Route: IV Auld Notes: 1000 cc per hour, 1st IV site Ordered by: (b)(6); (b)(7)(C) Thu May 17, 2018 IS:17 Ente� by: Acknowledged by: bl(6l: (bl(7)(Cl Thu May 17, 2018 15:20 Documented as given by:!(bl/6): CblC7lCCl !Thu May 17, 2018 15:36 Patient, Medication, Dose, Route, Schedule verified prior to administration., IV SITE# 1 IV fluids established, IV SITE# I 3rd bag hung, amount I Liler, IV SITE# I bolus of 1000 ml established, JV SITE #1 on IV pump, Connections checked prior to admlnisttation. Line traced prior to administration, Catheter placement confirmed via flush prior to administration, IV site without signs or syrnptoms of infiUratlon during medication adminisiration, No swelling during administration, No drainage during adminisc:raUon, IV nushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised or aclions and side-effects prior co administration. AJlc:rgics confirmed and mediations reviewed prior to administration. Patient in position of comfort, Side rails up, Cart in lowest position. : Follow Up: SITE #l :_, JV fluid Infusion discontinued, on Thu May 17, 2018 16:40, Total amount infused: 1000, Advised not to ambulate without assi,iancc, Patient in position of comfort, Side rails up, Cart in lowest position. c1� sodium chloride 0.9 % inrravenow: Order: sodium ch.loridc 0.9 % intravenous 0.9 % Dose: I 000 mL Route: IV Auld Notes: l000 cc per hour, 2nd IV silC Ordered by: (b)(6); (b)(7)(C) Enlercd by: Thu May 17, 2018 15; 17 Acknowledged by: fh\lR\ 1h\/7Vr.1 IThu May 17, 2018 15:20 Documented as given by: Kb)(6); (b)m(c) IThu May 17, 2018 15:36 Patient. Medication, Dose, Route, Schedule verified prior to administration,, Amount given: JL, IV SITE #2, IV fluids euablished, 4th bag hung. amount I Liter, IV bolus of 1000 ml established. via prim&ry tubing. on IV pump, Connections checlced prior to adminatration, Linc traced prior to administration, C11theter placemen! confirmed via flush prior to administration, IV site without signs or symptoms of Infiltration during medicalion 11dministra1ion, No swelling during administration. No drainage during admlnistradon, IV flushed af\er adminisuttion, Correct patient, time, route, dose and medication con(lfflled prior to administration, Patient advised of actions 11nd side-effects prior lo administrallon, Allergies confirmed and medications reviewed prior to adminisua.tion. Patient in position of comfon, Side rails up, Can in lowest posilion. : Follow Up: No signs or symptoms of 11llergic reaction noted, _lV SITE #2:_, IV fluid infusion discontinued, on Thu May 17, 2018 16:40, Total amount infused.: 1000, Advised not to ambulate withoul assistance, Patient in position of comfon, Side rails up, Cart in lowest position, Family al bedside. u,� \/6\ _rv kb I NURSING PROCEDURE: EKG CHART 11,mffiillill PATIENT IDENTIFIER: Patient's idcnllty verified by patient $tiling name, hospiral ID bracelet. EMS/police officer. POU.OW-UP: After proce.dute, EKO for inlCrpretation given to l(b)�1;�, NURSING PROCEDURE: INTAKE AND OUTPUTc1t�c1M1 Pn:pan:d.: Pri May 11, 2018 01:42 byl(b)(6); I 2020-ICLl-00006 1050 o&,1a1201e oe;o1 Fro,n; #393 P.D20/032 HERNANDEZ,JEFFRY DOB: 2/18/1985 Mll Wt/Ht: MedRcc: 166116 AcctNurn: 4499030 CIBOLA GENERAL HOSPITAL ED PRINT INTAKE AND OUTPliT: Total Intake (ml): 0ml, Urine output(ml): 750, Total Output (ml): 750ml, Gnnd Total: Ou1pu1 is greater than intake by 750mls. NURSING PROCEDURE: IV PATIENT IDENfTIFIER: Patient's identity verified by patient stating name, patient stating birth date, hospital ID bracelet. moo!/bl/6):! . . Patient's identlty verified by patient stating name. pa1ient stating birth date. hospital ID brac:ele1. (14:l�(b)(6);! IV SITE/: IV therapy indicated for hydration, medicalion administration, JV established, lo the right forearm. using an 18 gauge catheter, in one attempt, IV site prepped with Chloraprcp. Salin� lock established, Flushed with normal saline (mis): 10, Labs drawn at time ofplac-emen1, labeled m the presence of the palicnt and sent 10 lab, Blood cultures drawn at time of placement. labeled in the presence of the patient and sent to lab. mail(b){5);! Flushed with nonnal saline (mis): 10. r14:1okbH6l /V srrE 2: IV therapy indicated for hydration, medication administration. IV established, to the left forearm, using an ! 8 gauge catheter. in one attempt, IV site prepped with Alcohol. Saline lock established, Labs drawn at lime or placement, labeled In the presence of the paticn1 and sent to lab. 11•:14{b)(6) SAFETY: Side raJu up, Cart/Stretcher in lowest position, Call light within reach, Hospital ID band on-111aijcbl(6l Side rails up, Cart/Stretcher In lowest position. Call light within reach, Hospital JD band on. IIH� I I I NURSING PROCEDURE: NURSE NOTES lll:l�(b)(6) l NURSES NOTF.S: Notes: PaUent is Dlaphoretfc, patient states she bu been dfaphoretic for 1 hour, SAFETY: Side rails up, Cart/Stretcher in lowest position. Call light within reach, Hospilal ID band on. NURSING PROCEDURE: TRANSFER TRANSFER.· Diagnosis: Septic shock. Accepting in.s1l1ution; Lovelace Downtown, Accepting I. I Referring physician: !rbl/6): Noles: Room 7126, number for physician: th1tfn· lhlm1r., report is S0S-727-{1fil@l 111,,1,11h11R1i Diagnosis: Sepsis, Accepting lnstitulion: Lovelace Down town, Accepting physlcian{b)(6); �. Refming physician: !(b)(6), Report called 10 receiving facili1yJ1h)l6l L flN, Provided opportunity to answer questions, Bed assigned 7126. 11,,:ui illillfil:] Transponed by Reason for transfer need for specialized care, Referring physician*b)(6); helicopter, accompanied by emergency medical services personnel, Report called to receiving facility, !(b)(6); !RN bykbl/6): !RN earlier no change, Summary of C11re printed, Copy of patient rcco«i prepared for receiving facility, Patient consent for transfer signcd.r.1:>"llhvfl,·I I L I NURSING PROCEDURE: URINE COLLECTION uuo� PATIENT IDENTIFIER: Patient's identity verifled by patient suiting name, patient staling birth dare, hospital JD bracelet. URINE COLLECTION MALE: Uritie collection indicated for patient unable to void, Coude cathe1er inscned, using a 16 fr coudc catheter, in one attcmf)f, urine yellow in color, and clear, Specimen collected, labeled In the presence of the patient and sent 10 lab, Specimen obtained for culture labeled in the presence of lhc patient and sent to lab. SAFEr'I: Side rails up, Cart/Stretcher in lowest position, Call light within reach, Hospital ID band on. VITAL SIGNS VITAL SIGNS: BP: 80/56. Pulse: 131, Resp: 31. 02 s■r: 89, Time: 5/1712018 13:47.lu,n lfh)(R)·I Pnpan:id: Frl May II. 201101;◄2 bYilh\ln\· I .t[,; 1· I flliill[] llh1(6)· (hlf711C\ CCS-Ciuula Pase: 16of 11 2020-ICLl-00006 1051 l ;,.� 0 06/18/2018 00:01 From: v V CIBOLA GENERAL HOSPITAL ED PRINT #303 P.021/D32 HERNANDEZ, JEFFRY DOB: 2/18/1985 M33 Wt/H1: McdRec: 166116 AcctNum: 4499030 BP: 88/64, Pulse: 134, Resp: 27, 02 sat: 89, Time: 5117120 I B 14:01. ou11!1h\/R\ I BP: 82/57 (AUTOMATIC), Pulse: 137, Resp: 18, Temp: 104.9 (TEMPORAL), 02 sat: 89 on (ROOM AIR), Time: SI 1712018 11 :59. c11:,i!(bl(6l:I BP: 86/62, Pulse: 131, Resp; 34, 02 sat: 92, Time: 5117120 I 8 I 6:00. (16:00 (b}(6 BP: 91167, Pulse: 127, Resp: 30, 02 sat: 92, Time: 5/ 17/2018 15 :45. c 15,u }; BP: 84148, Pulse: 173, Resp: 18, 02 sat: 92, Time: Sil 712018 17:45. m,•1 (?l\7 BP: 8 I /49, Resp: 17, Time: 5/17/2018 17 :30, 01:10 lJO noq/dL 116 6l )7 1.0 8.2 5,5 1.7 a., 115 )!I) RATIO m.L/min/l,7lm2 IU/L IU/L IU/L mq/dL G/dl. 17/dL r,,q/dL "'9/dL IU/L U/L IU/L lOB 0.056 1-8 nq/mL 2.0 11111101/L o., RATIO 11J11J{dL 05/17/18 18,15 Inhnta {1 · 23 monthal , 0.867•6.4) uIU/IIIL Cb.lldren {2 • 12 Year.al , 0.704•4.01 uIU/mL Adole11cent11 \U-20 ye11r11) , 0.516·4.ll uIU/11\L >JO yea.ru, 0.)58·3.740 uIU/1111. ······-·······�·-··-·-····················�······ ··········-···��··-···-···�-�---�·-·-··········-· ALL T&H VALU!S R.EPR.t9EN'l' 3RD Q2tl£AATION �SH SOURCE IN!"ORNATION, '), � 'I -hK�)( ! DXHBR RBIPOR'l'Ji:D DT ™ . . . .. . . . 9 .8 0,8 25 0 . . ♦ • • • ♦ u.s 1.2 40 2)0 VNITS . . . . .. . . . .. . . . . . . . . .. . . . Sac:ond11 INR Seeonde ng/mL 05/17 /18 14 :31 INR Primary and aecondary prevention of vanoua thr:omboai IS 2 • :, Provonl1on ot rOC\lrr•nt venous thro:abooio 2 .5 · l.5 Prevention of arterial tbromboelNloli""" including patients with II\IIIOMnioal boart valvea 2.5 · J,5 ••• New Protllromhin Ti�o roforonoo ra.nge atfoc:tive 2·1·18 2.5 ).0 3.0 •• Cibol� Oonoral Hoepital Laborftto,:y •• Heparin TMrapoutio ranqe for APl'"l' la 48·?4 aeoonda. The lll&t\Ufaoturer of tho D·Dlmsr aeeay h•a approved a aut-aff of llO nq/ml. The m1111uf•oturer 5tate• that with thla 01o1t·o£! th.o Neqatlv@ Pro,dictiv" Valua of tho togt la 100\ with &poc1f1c1ty botwoon l6\•l8\. D·Dimar roaulte •ro reported in nq/a\L, Thaaa unlta c:orreapond to ng/mL of D·Dilller Unit& (D·DU). SOURCE INl'OR.KI\TION, 5/17/18 13,04 PT 5/17/18 13,54 APM' 5/17/11 13,S4 D DXMER Blood Blood Blood (c�)-.....J�m i.:.;(l b..:... )(6;;...:.);:...:.(b�)('""'? )""" CCS-Cibola 2020-ICLl-00006 1055 . . . . . 06/1B/2018 08:02 From: Print ct.,,te, 5/18/18 Printed by, !1h1rn1- 8,4J RB PO ft T C U M U L A T I V E Selected £ncoW1teru P.l.Q'B LNIORA"t'OR'lf !(h)(n)· (h)/7)/C:) C:CBOL.I\ QElfi;RAL NOliPITAL 1015 E. llOOSBVBLT AVB c:RANT1I NH 87020 DOB 1 2/18/85 li!llr M A0B1 l.) NAME I HEJUU.NDEZ. J.!PPRY MRI , 0001456116 #393 P.026/032 M.J). PCP, NONB LOCAL HEMATOLOCY COLLEcT l'R DT TM 2018 05/17 ll,04 we REY2RENCE LOW • HICK S.6 3.16 L 8.6 L 25.l L JUIC HGB IICT MCV l.6 4.64 12.0 ]6 80.1 L NCH 27.2 L RDW 14.. J H 81 27.6 JJ.O n., l'KKC " PLTA � 10.7 42.9 ll. c 22., BA\ 0.6 NElf 2.4 KPV � L'A 11., 150 L 1.4 11 ,., 6.00 16.0 48 ,a JJ.) l4. 8 1l- 7 no 10 .• Ll'II MOIi BOit llAlt MAN l>IF, 1-9 1.) o.o 1.8 1.0 " 0.2 o.o 0.0 0.0 l'ES 42 NEUT 40 s BAND Ll'MP lS 18 H 0 DECR.EASB HONO'\ B09 PLT' EST RBli'OR:'l'ED DT ™ fL ' P9 C/cU. ' 10" ]/UL fL ' ' 'I 'I o.;a EO\ 10/3 "L 10"6/llL C/dL 7.0 ) .4, o.a O.l 0.1. 76 0 5 2 47 10 16 D 'I 1.0"l/uL 10")/uL 10"3/uL 10'3/uL lO"l/uL s.o 05/1?/18 13,25 SOURCE lNFORMTl"ON, 5/17/11 13104, CBC COMHBNI'S, 5/17/18 ll,25 CBC Blood Pla�alet OYQluation eqroea wlth autOl!>atod count Faw aaudqa calla prooent --�m 2020-ICLl-00006 1056 !.,_, OD I .I/U/8'5 ACll, ll asx, H PCP, NONE LOCAL IMHUNOt.oGY COU,!CT YR DT TM KIVRA.PID 2018 05/17 13104 UFERKNCr: LOW • R.BACTIVB RE:POkTl!;tl DT '™ JfICK UNIT1l NOH R£AC't'IVE OS/11/lB l7,4S Thia report la confidential and 1u prota<:ted by Federal i..aw. Federal R.equl�tlon (4Z CFR, Part 2) proh1b1tu you from -kinq any furchor dioclosure of it without the opacific written conoont of tho parson to who� it pertains, or •u othorwiao permitted by ouoh l"OJQ"ulationu. A qoneu,l 11uthor.l.:"tion for the rolo�aa ot llltlldical or other infonnation lo NOT oufficient tor thiu purp,ooe. A raeult reported aa "Reactivo·• will be automatically confiEllled by Weotarn Blot. SOURCB INPORMATION, 5/17/18 15,1' HIVltAPID Blood C0fo!MlruTS1 5/17/18 17,45 KIVRAPID Repeated To be uent out to Roforonco wb for confiTIIWtion __.f', 0 )(C=l_ bl-'-'(7.,_,_ .,.,(b ! '-'-'l(=6l....,_ : f:::..: CCS-Cit.,o\..i 2020-ICLl-00006 1057 06/18/2018 09:03 From: P�1nt data, 5/18/18 8143 Printed by, k�h�)=R�) / -· -� C U M U L A T l V E Paga RB PORT t.ABORATOR't CIBOLA GENERAL HOSPITAL 1016 B, ROOSEVBLT AVB aRANI'S NM 87020 MAKE, HIUI.NANDEZ. JBf'P'IU' MRII : 0001156116 #393 P.027/032 fb)/6): (b)(?)(C) DOD, N.D. PCP, HONE LOCAi., l/18/8� SEX, M •••MICROBIOLOGY••• COLLECT 'tll DT DI STRBP 2D18 DS/17 17,06 Ul"BRBNCB LOW · HICH NEOATrvE RBPORTEll DT ™ UNITS NKCATIVB 05/17/1' 17,16 All noqat1ve Strap acreonD will be confinaod by culture. kh)IR)jh)/7)/(:) CC�i-Cluulo 2020-ICLl-00006 1058 ! ,\, J 06/18/2018 09;0:S From; Print da�o, S/lt/18 ! Prlnted by, !(b}(6}; 1,41 A 8 P O R T C O N U L A T 1 V £ Soloct•d EnCOW\t•r• Paqo CI801.A QENEJUU. HOSPITAL 1016 I, ROCSIVBLT AV'II NM 870l0 GAANl'S NAME, Hl!RNANl)EZ JBFFRY HRlf , OO01n1u 11393 P.028/032 1.NIO!lATOAY DOB, 2/18/85 AGE: J) SE.Ko M URINALY&tS COLL�CT n 2018 OS/17 DT TM UCOL.Oll CL.AAITr SPECCRAV UPH ltEFlllUSlfCB LOW • HlOK U:20 YBLLC»f clear 1.015 1-00s s aLuco,z Nl!aATIVE NEQATIVE NIGATIVE 2♦ l+ Nl!OATIVE BILI UTOtmS PROTl1111 UROIULB NI'l'llXTB 8.1.00D NBQ nae NEO NIia FEW AAIU: RARE 0 RZPORTEI> D'T '11!1 1 /UPI' /HPP' 0 /KPF /LPf /KPF 05/l "I/ll SOURCI! lNFOIIMATlON, S/17/18 16,17 UA COMl1Etff'S, 5/17/18 15,S3 UA neg 2 RAaE .nw CRYffALS CASTS 0 0 0•2 EPrrH mv/dl. NEC O· l IUIC BACTEJUA a Nl!O NeGATXV!: WBC l.O)O NBC 1♦ LEI.JUST 5 U:53 URINE CLu.N CATCH F- llf'IIOrpho"" ccyotal� Catl\otor Urina M1croocop1c 1111d 111acroseopic reo\llt■ rovlewod for correl&tion l/h)/fi\· (h\n\lG\ 2020-ICLl-00006 1059 CCS-Cibola IMO 1 0001 User: !_�_X_�_; __ Page: Date: Time: R E S U L T S R B P O R T I N G ClBOU. GENB.R.\L HOSPITAL 1016 E. ROOSEVELT AVB, GRArfl'S, NM. 87020 PH# 1505)287·4446 M.o. Medical Oirect��:�b��JL(l��l . I Name: HERNANDEZ JEFl'RY K/RI: 000166116 Patik 409030 Ord#:R 2300 Current Test PATIENT ABO GROUP ANO Rh PATIENT ANI'I800Y SCREEN Special Instructions: PINK TOP TUBE DOB: 02/18/1985 SEX: M LOcation: ,-o/P --' ,.., ""..,,:-c Ord Phys : 1,b l(-6)-: -,b }( 7) (C)---,1 w Collected: Received: Reported: Blood Administration Result Rep<>rtinq Abn Previous Result Previous Date Result 0 POSITIVE History N/F 05/17/2018 History N/F OS/17/2018 NEGATIVE COMMENTS ,,.. 0 l 5/18/2018 8:43 3 5/17/18 5/17/1B S/17/18 verified rrr/TM/� 5/17/18 17:02 (b)(6 5/17/18 17:02 i,� ( "'..... Cl Cl .... C .. � 0 Cl 0 G " • 0 C (_ (. � '\.., ,.._ :.-. I,,\ G w ' .... Tc � l� �l "0 0 N G .... CJ 5/18/18 4499030 HERNANDEZ JEFFRY 2020-ICLl-00006 1060 8:'13 0 c.l N 06/18/2016 09:03 From: 0 u 0 �8028033:Sl � �8� 8�8i 41, CIBOLA GENERAL HOSPITAL P1t1ent Report Legally authent1cated Rad1olog� Deiartment 7020 GRANTS M 1-505-�8 -52 0 RADIOLOGY REPORT Pt. Name.: HERNANDEZ, JEFFRY Jacket g: 166116 DOB: 2/18/1985 Pt Type: 0 Rm fl: Sex: M Exam Ot: 5/17/2018 MRN: 166116 User: .383 p_03O/O32 kb __);"---__. ._.:..;.J(6 Page Referring phys1c1an· kb)(6); (b)(7)(C) PROCEDURE: CT ANGIOGRAPHY OF THE CHEST WITH CONTRAST INDICATION: 33•year-old male with elevated d·d1mer and hypoxia TECHNIQUE: Hult1detector CT 1mag1ng of the chest was performed follow1ng the 1ntravenous adm1n1strat1on of 100 ml of Isovue-370. Coronal 1m�ges were then created from the ax1al data. 3·0 MIP refQrmatted 1mages were also obta1ned. one or more of the fo lowing dQse reduct1on techn1Ques were used: Automated exposure control. adjustment of mA and/or kV according to patient s1ze, and/or use of tterative reconstruct1on technique. COMPARISON: None FINDINGS: There 1s adequate opac1f1cat1on of the pulmonary arter1al system. No f1ll1ng defects are seen to suggest pulmonary embolism. Numerou� bllateral pulmonary mtcronodules are seen, all m�asur1ng less than 6 mm. Mult1ple enlarged mediast1nal and bilateral hilar lymph node� are seen. A few such lymph nodes 1n the left h11ar region conta1n coarse calc1f1cat1ons. Although top d1fferent1al constderatton would 1nc ude granulomatous d1sease su,h as sarco1dos1s. mat1g�ancY. 1s to be excluded. Recommeod EUS to fac11itate FHA of one of the abnormal mea1asttna1 lymph nodes. No pulmonary parenchymal consoltdotlon. No pleural or pertcard1al effusions. The v1sua11zed upper abdominal contents are unremarkable. The v1sua11zed osseous structures are unremarkable. IMPRESSION: No evtdence of pulmonary embolism. Numeroui btloteral pul�onary m1cronodules and mu,ttole enlarged �ed1ast1nal/nt1ar lymph nodes ire seen. A few such lymph nodes tn the left h1lar regton cont11n co�rse calc1f1cat1ons. Although top d1ffer,nt1al cons1derat1on would 1nclude granulomatous disease such as sarcotaos1s. malignancy ts to be excluded. Recommend EUS to facfl1tate FNA of one of the abnormal medtasttnal lymph nodes. �b)(6)· (b)(7)(C) I NTERP RETEO AND ELECTRON I CA LL 't' SIGN ED BY: .... -' � ------�·I MD on 05/17/2018 at 04: 52 PM RELEASED BY: 85 on 05/17/2018 at 05:08 PH INTERPRETED and ELECTRONICALLY SIGNED BY: Dtctated Date: 5117/2018 Transcr1bed Date: 5/17/2018 'NAME: HERNANDEZ JEFFRY Exam 0: 44990300002000 Exam Dt: �IMo � ._b_)(6_);_(b_la_l<_ci___ C1bola General Hosp1tal 166116 5/17/2018 Leoally authent1cated by j(b)(6);(b)(7)(C) l201B·OS-17 17:08:01 Electronically Stoned By:�Pn.,;.,Y;...sr-'--'..;._;_--=n-=-o•t -::o:-::n�f1le 2018-05·17 17:10:42 ,- )'I. /iCMh\/"l rE2.Li !(bl(6l: {b)(7)(Cl 2020-ICLl-00006 1061 CCS-C1LH;lcl j!vl 0 1 #393 P.031/032 06/18/2018 09:04 Fram: D aS01Soa 3=54 Dsaa1 4i,i��� CIBOLX GENERAL HOSPITAL Rad1o1ogi oegartment 020 User: Patlent Report Legally authenticated Page Ki;._b;._;.)(6__):___, 1 ���g!��a?�szs� RADIOLOGY REPORT Pt. Namt: HERNANDEZ. JEFFRY Jacket D: 166116 DOB: 2/18/1985 Pt Type: 0 Rm II: Sex: M Exam Dt: 5/17/2018 MRN: 166116 Refwr1ng Pbvs1ctar: )(6); {b )(7)(C) MO 7 3 3 41 PROCEDURE: PA AND LATERAL CHEST RAOlOGRAPH INDICATION: Cough, fever. headache. abdominal pain x5 months COMPARISON: None. FINDf NGS: The ungs are well aerated. No focal consolidat1on. edema, pneumothorax or pleural effusion. The card1ac silhouette 1s w1th1n normal 1lm1ts. The v1sual1zed osseous structures are unremarkable. IMPRESSION: Normal chest rad1ograph. PROCEDURE: SUPINE AND UPRIGHl ABDOMEN RADIOGRAPH INDICATION: Cough, fever. headache, abdominal pa1n x5 months COMPARISON: None FINDINGS: There 1s a nonobstruct1ve bowe1 gas pattern . Large quant1ty of small and large bowel gas 1s seen 1n the mid-upper abdomen. No free 1ntraDerttoneal air on erect v1ew. The v1sualtzed osseous structures are unremarkable, IMPRESSION: No rad1ogrJph1c evidence of small bowel obstruction. Large quanttty of small and large Dowel gas 1s seen 1n the m1d upper abdomen. !�TS���iT�� AND ELECTRONICALLY SIGNED BY: RELEASED BY: 85 on 05/17/2018 at 03:37 PM ( () 7_)(C_l__ I b_) ( (6_J;_b _� L... _ INTERPRETED and ELECTRONICALLY SIGNED 8V: Dictated Date: 5/17/2018 Transcribed Date: 5/17/2018 'RAME: £xam #: HERNANDEZ JEFFRY 44990300001900 Exam Dt: ( (b)(7)(C) !(b)6); MD on 05/17/2018 MO Cibola Genera1 H9$�1ta1 5/17/2018 16 6 116 I Legally authent1c;ated by �b)(5);(b)(7l. IDJI r:), (b)/7.J.K:'(� '/ __.......-;...\'()U �r.S"'"" ADDITIONAL Comments: '\.J III. SPECIAL NEEDS AFFECTING TRANSPORTATION Is prisoner medically able to travel by BUS, VAN or CAR? Yes D No D If no, Why not? Is prisoner medically able lo travel by airplane? YesD No D Is prisoner medically able to stay overnight at another facility en route to destination? YesO No D If no, Why not? Is there any medical reason for restricting the length of time prisoner can be in travel status? YesO No D If yes, state reason: Does prisoner require any medical equipment while in Transport status? YesO No D If yes, What equipment? Sign & Print Name Certifying Health Authority: Phone Number If no, Why not? Date Signed: Prisoner FIie Form USM-553 2020-ICLl-00006 1065 (Est 6198) lti - ·-·A•-·· -· . CS .... , C V HEALTH SERVICES NOTICE CORRECT C RE S O L U 1IO NS NOTIFICATION OF MEDICAL SERVICES·· CCS provides the medical care at this facility. If you have any special medical or emotional problems, please be sure to infonn the nurse or doctor of your problem at the time of your interview with them. HOW TO SIGN UP FOR SICK CALL • If during your incarceration you wish to see the nurse or doctor concerning a problem, submit a medical request stating your problem and put it in the me.dical request box. Me.di cal requests are collecte.d daily and reviewed by the appropriate medical personnel. HOW TO INFORM STAFF OF A MEDICAL EMERGENCY - If you have an emergency medical problem, please contact a correctional officer immediately. He/she will contact the proper medical person or hospital to handle your problem. lf you have any questions about the medical services provided within this institution or how to properly contact the appropriate person, please rerer your questions to a correctional officer or to a nurse for clarification. ACCESS TO DENTAL CARE - If you have a dental emergency, please contact the Custody Officer immediately. He/she will contact the proper medical personnel to handle your problem. AVISO DE SERVICIOS MEDICOS - CCS suministra asistencia medica en csta institucion. Cualiquier problema emocional o fisica de] cual ustcd padezca, sc lo puedc infomar a la enfermera o medico cuando hable con ctlos. COMO OBTENER SERVICIO MEDICO - Si durante el ticmpo, en que usted esta en esta institucion dcsca vistar a la enfennera o al medico por problcma de salud, finne la lista de doctor o la enfermera. Luego, Hene la forma y cntreguela en la caja de solicitudes mcdicas. Estas listas scran recogidas diariamcnte y revisadas por el personal medico indicado. COMO INFORMAR DE UNA EMERGENCIA MEDICA - Si tiene una emergencia medica, llame al sargento de oficial inmediatamcnte, El/ella hara el contacto con el personal medico o el hospital para ayudarlc. Cualquicr pregunta que usted tenga sobre los servicios medicos suministrados en esta institucion o coma haccr el contacto con la persona adequada, par favor refierase al oficial suyo o a una enfennera para clarificar). Si tiene una emergencia dental par favor comunicase con un oficial ACCESO ATENCJON DENTAL imediatamente y else comunicara con la persona apropiada para su problcma. p MAY 1 7 2018 (b)(6); (b)(?)(C) All ___,IRN l(b_)(6_);_(b _)(?_)(_C)__ .... Signature/Stamp of Healthcare Staff Date MAY 1 7 2018 Date LN'i Sr�_,., ,yJ; Detainee Speaks Er1glish v or 1 Staff Speaks Detaincc's Langua�r N Language Spoken: · ou use interpreter or b)(6);(b)(?)(C) ]/h \ffi\· I DP. nla ! Assistant N Name/Number: __, ,__ CCS-Cl80LA ___ 2020·-1cu-00006 1066 A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MllAN, NM 87021 ccs CORRECT CARE S OL U TIO N S INTAKE EDUCATION INFORMATION MY SIGNATURE BELOW INDICATES THAT I HAVE RECEIVED VERBAL AND WRITTEN INSTRUCTIONS ON THE FOLLOWING TOPICS DURING INTAKE: A. ACCESS TO THE MEDICAL DEPARTMENT FOR ALL OF MY HEALTH CARE NEEDS. B. NUTRITIONAL INFORMATION C. PERSONAL HYGIENE INFORMATION D. ORAL CARE AND HYGIENE INSTRUCTIONS E. HIV/AIDS INFORMATION F. HEPATITIS INFORMATION G. TB (TUBERCULOSIS) TESTING AND PREVENTION H. INFORMATION ABOUT BOILS I. SUBSTANCE ABUSE J. SEXUAL ASSAULT PREVENTION K. KEEP ON PERSON (KOP) SELF MEDICATION PROGRAM 1 --­ Detainee Signature: -=J_,_-1t....:-�-1-- -------.-�.......,, (b)(6); Date: MAY 1 7 2018 (b)(7)(C ) ;;--17-/fJ . (b)(6); (b)(7)(C) cr.s.-Cibola Octamee A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 RN � Speaks English Y or ".N} Staff Speaks Detaine�. L-rnguage29 or N Language Spokcn:�4l'IA"· '!)�1-i '-'-c..-. 2020-ICLl-00006 1067 - · · · "? (D�d you use interpreter or '(L)or N Name/Number·_(b)(6); ~ (b)(6); ental Assistant GCS-ClbOLA INTAKE CHECK LIST ARRIVAL DATE: -=---=----='-------S-1b-18 Time Seen (By Medical): 5:-1?-18 073� Detamee · Name:_ A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 ARD: 05/16/2018 M A#______ CCCC/MILAN, NM 87021 Language: _Sp:t,,u1.5lf Language Line Used: ..::.Y_____-=-S-= elf =- l(b)(6); (b)(7)(C) � Has Detainee Been Here Before: --,"..., /o "----------__ TB Test Given: MAY 1 7 2D1B CXR Date: ______ H&P Date: _______ Chronic Appointment Schedule Within 24 Hours All Other H&P, Schedule Within 14 Days of Arrival Provider Referral (If Applicable): __________ Mental Health Referral (If Applicable): ________ 5.17./f� (b)(6); (b)(7)(C) ccs-C\bo a 2020-ICLl-00006 1068 MO µP,. . ' ----........_- ..... -... ......... ,.... I (b)(6); (b)(7)(C) 11.A .,________. slodi0-8:J..., .. (b)(6); (b)(7)(C) 2020-ICLl-00006 1069 •-•·= �-______________ ·, · f i_ T ��--,,_.; _;: �.ICCS Page 1 of 4 CORRECT CARE SOL U 1 10 II S RECEIVING SCREENING Last name Ml Fist name ID# Booking ID# I DOB Sex l')c;-/r7 I � n-/,, _It,,,. I I '---"'� Booking date Timef')J / -n, Previous incarceration No p< Doctor Phannacy Health insurance Policy holder name iL 1/r,, I BP Vital signs Are you on any medications? Unknown F ,.,,� SS# lb 5/;7/)f dale When 70?0f.S V Company name (']7 3.S- _,,, � rJ ,1 .Ai.. �-""" / Location (.,.,- 15"honc I TI me Location Phone ID# p Yes ,:') ' j� � 1.!"-' �ntake Location y Group# ,,..., 5' Unknown Yes ., IVrl(... . ..M' r1plt � nro RR List medications I 1/h T /OOJ li" Spo21\ J't, 1 /.1.;? _/) tfiJ09(jt'J I II HT�IJ l w 1!9 If yes to current meds or psych mcds, perform Medication Verification and refer patient for provider examination. Medication verified Yes I Are you allergic to any meds Yes I Comments Other allergies No / J;J.e- I MAR written? {If no, place on MD call line) I List medications Food Yes Other Do you have any medical problems i.e. heart problems/seizures? � (No_,,, Yes No � NCI" Yes J>l(j N5 Yes Have you recently had any head trauma with loss of conscience in the past 24-48 hours? Any infectious disease? l>kf"' Yes Yes When Tx/CXR fl.t II(£) /Ji/t§P IJ ) /°./. � .. .refe.f-t'6provider Current symptoms (check any that apply) any 2 triggers, initiate Tuberculosis Proto'c\..1 1l Chronic cough y Weigfllloss Y' Chills Loss or appetite Night sweats Fatigue y:. Other Have you been diagnosed with any of the following? (check any that apply) Hepatitis A X Other Infectious Diseases X HIV/AIDS History of active withdrawal/sei�_ur?? Describe symptoms Yes I Tuberculosis I .Nef I Shakes Yes I t,ig- If yos, refor immodiatoly to provider: and initiate Alcohol Withdrawal Assossmont Record. Do you drink alcohol? I When was last drink? I Yes %I If daily, rcfor immediately to provider. Do you use drugs? Yes Quantity Beverage of choice ";7'"j List I Blood Alcohol Level I II Weakness Fever Chest pain No � Yes Recent hospitalization? I NO KNOWN DRUG ALLER( IES A.Q/LJJ// Seasonal Have you ever had a positive TB test? Yes ! Coughing blood "'-.lO STD - I Seizures Yes I },,la- I Frequency I --, nmc If oplatc/bcnzo, refer immediately to provider. Fom111 00062 ( Authority: t-1-01 I E!lective Date: 0115/2011\ Revision Dale: 4/2212013. 2020-ICLl-00006 1070 A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 V Page 2or4 RECEIVING SCREENING Yes Are you having any visual hallucinations If yes, refer Immediately lo medic.al staff. I I Diaphoretic I Do you use lobaa:o products? I Lelhargic Do you have any dental problems? I Nausea I I Hyperactive Yes � Cigarettes Yes .)Id" Caries Do yoo have a medical candltlon that requires a special diet? Es:male� aabl Are you pregnanl? Yes If yes, prenatal care? Yes �pe9ranoe State of consciousness Disheveled V Responsive Disoriented Regular Breathing No No / Anxious Normal Hyperv&ntil8�ng Tremors I/...Cough Wheezing LMP Yes I other Dentures other Other !UPT .,,, �Hostile Appropriate Aggressive Cooperative Normal /' Crutches Normal Skin low No/Fat Diabetic I EsUmaled due date Mobility / Chew/ Smokeless Low Sodium I Diarthea Vomiting Hallucinating Ue""" Pmnatal Beh8'.'ior Lethargic Alert I Tattoos Ump Wheelcha!r I/ Rash Needle mal1t6 Yes Yes In the last 6 months? Describe ooes the booking officer or other external sources believe that lhe patienl is suicidal? Yes Does the pall8fll expnr.;s feelings of hope{essness/helplessness? Yes Has tho patient experlonced loss of f'amilylfrlend In last 6 months? Yes Does the patient show signs of depresslonh!molional flatness/ayingfanxiety? Yes � � Yo )16 If yes, to any to tho above 4 questions, e,,:plain Prison Rape and EllmlnaUon Act - Nex1 8 quesUons Ye& reaDcnses should bo rof1mcd to classlRcaUon fer further evaluatlonlhou&lng decisions. 1 Have yoo been approached for sex Of been a victim of sexual assault whlle Incarcerated? I Yes 2j Have you been a victim cl unwanted homosoxuality? j Yes 3) Are you concerned about being sexually assaulted or ab11Sed while inca�rated? I I I Eiq:,lain I Explain I Explain I 41 Do you have a histOf)' olsexua1 orviotentconvictions? sj I : E)(J)lain Does the patient Identify as, or is perceived to be homosexual, feminine, transgender, (or in process of change) or diannosed with oender ldentitvdisoroer? Explafn I Form# 000021 Authofity: H-01 I Effedive Da 13 Yes Vos I y.es- . A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 No Page3 of4 RECEIVING SCREENING 6 Does the patient eiq>rass that they are, ar Is perrelved to be: unable to protect self in prrsoo/jail; will be pl eked on or �Iliad other inmates· or is small sfz.i;,�.®f 5_'8")Llh.ln.!!!,Jild [und!lf 130 pounds), frail, or youthful appearance? Explain 7 OevelopmentaUy disabled, confusedfdisoriented? E>cplaln 8 _ Other problems not addressed above? Yes Yes Yes Explain Description of lnJuries/ObJectfveObservations: , Brulse/s: 2 Contusion/redness: 3 Laceration/s: 4 lncislon/s: 5 Soreness: 6 Swelling: Other; 7 Pt sml'B> l..()t'£t.vj' A a,r e, T"H6 1(...., __,, we /,.,'l-5T ;np;.,/171 4"10 A frf-14t,.F, 1,v \'au Ld'l $Ide Vnr Ripe Siok .. Disposition: (Check asappropnate) Frolll ......... _ Fool Your Rl,:hl SW< ...... . ·--- Bark General population Suicide watch Referral to medical provider Lower level Referral to mental health Lower bunk Negative pressure room Mattress Referral to external health care facility (Facility name); (b)(6); (b)(?)(C) Signature Title Date/Time I, the undersigned, affrrin that the above information is correct to the best of my knowledge. In addition I have been provided infQ,nnation verbally, and in writing on how to access medical, denl,{111, and mental health services al the facility. MAY 1· 7 2018· . .t i �t�l!Jre Date Detainee Speaks English Y or � Staff Speaks Detaince's Language:@>r N Language Spoken: �Gd:a� d _,..Qjd you use interpreter <:!.,yr N Namc/Numbc ? Time Etr� Date: 8/15/20111 Revision Date: 4/2212Q1l, 6. A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 l(b)(6); P,�nt,a 1-h.ssls.ta nt1072 2d&�eb�uuo CCCC/MlLAN, NM 87021 •ices CORRECT CARE S OL U TIO N S CONSENT TO MEDICAL INTERPRETATION Facility Name:________________________ Oetalnee's Name (Nombre del Recluso): Detainee Number (Numero del Recluso): ------------::----­ Date/Fecha de Hoy: => _.,, I '1 .., ( � Time/Hora: _0_1_3_5 __ AM/PM I acknowledge that I am in need of an interpreter to discuss my medical condition. I authorize the Health Services Staff to share confidential information with the interpreter in an effort to completely explain my medical condition to me. I understand the interpreter has agreed to keep all of my medical information confidential. This consent is to be used for all future medical encounters from the above signed date. CONSENTIMIENTO DE INTERPRETACION MEDICA Reconozco que necesito un interprete para hablar de ml condici6n medica. Yo autorizo al personal de Servicios de Salud que comparta informac6in confidenclal con el interprete en un esfuerzo para explicarme completamente mi condici6n medica. Entiendo que el lnterprete ha acordado mantener confidencial toda ml informacion medica. Este consentimiento se utilizara para todos las encuentros medicos futures a partir de la fecha indicada arriba. MAY 1 7 2018 Signature of Detainee/Firm a del Recluse b)(6); (b)(7)(C) r 1 �(6); (b)(7)(C) CCS-Cibola I RN Staff Member Witness/Testigo !(b)(6); MAY 1 7 2D18 Date/Fecha Detainee Speaks English Y o�, Staff Speaks Detainee's Langu"�r N Language Spoken: �'i«1 ,yt; d you use interpreter or or N Name/Number (b)(6); (b)(7)(C) Date/Fe cha I Denlnl Assistant CCS-CIBOLA 2020-ICLl-00006 1073 A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 21 CCCC/MllAN, NM 870 pago4cf4 Patient Authorization and Consent to Medical Examination and/or Treatment I, (Print Full Name),_____________________. authorize the responsible physician or designee at(Facility Name) __________:._________ to administer medical examinations and/or treatment as necessary while I am incarcerated_ I also authorize any medical, dental, or mental health information to be exchanged with medical facilities or providers, or other correctional institutions in which I may be housed, as it pertains to my treatment. Spanish: Yo, (Nombre y apellidode lmpresi6n}_____________________ autorizo al medico o persona designada responsable en (Nombre de Facilidad). para administrar examihaci6n medica y/o tratamiento coma sea necesario mientras encarcelado. Yo tambien autorizo que informaci6n sabre mi condici6n medica, dental, salud mental, o uso de drogas o alcohol, ser cambiadas con otras instiluciones como pertenece a mi tratamiento. Signature: MAY 1 7 2018 Signature of Patient or Person Authorized to Consent Date ) (C_ ) __ ,_bf _(6) _;) (_b)_(7_ !fblf6\: Deni�! Assi.stan1 _ - ... CCS-CIBOLA" ' ._ _._. CCS-Clbo1a . ... . ;..· . 6418141 Form# ooosi I AtMority: H-01 I Effective Date: 8/15120111 Revision Dale: -4/22/201 A20 HERNAN DEZ, J EFFRV 2020-1 C Ll-00006 107 4 __,IRN DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 Medical/Psychiatric Alert_ The detainee name on this form has been examined and presents the following prob1cm(s): Psychiatric Medical Other □ D D □ @ □ Dx Dx H1 v @,,.t/E# tf Dx Detainee may require a medical escort if transported Ordered medications were received x7 days from sending facility � Transfer summary received from sending facility Other:-----�--------------------- Remarks: P6 hd$ 1' Zl5z?:t', m4n-!:th.., c:-i:,o�½'ne �S ) ); ( �b)(7)(C) (b 6 l Intake Nurse Signature Cee,1"'"1 u•?1&.-; obv,ol •xi_o\'3 OYes (8]No Malnourished? ··· · s,C'LJYes c c OYes OYes (8]No Shaking/tremors? OYes I , ' ,i !- \ .. Sex: Male 10/2010 12s)No A handicap? Referral for Immediate medical care l(b)(6); (b)(?)(C) .. ' .... DOB: 02/18/1985 Medical Clinic: MOBILE MEDICAL GROUP □ (8]No Cutsorbruises? (8]No Needle tracks? I Prinfj;ct name of individual completing the form Country of Origin: HONDURAS Date of Camp Arrival (DCA): 05/0912018 . ; OGeneral populallon with referral to 1nedical care First Name: ROY ALEXANDER A#: 206418141 OYes (8]No Sweating a lot? ng the form Last Name: HERNANDEZ RO RIGUEZ IHSC Form 794 ; (b)(7 ' '" Page 1 of 1 2020-ICLl-00006 1076 .. HERNANDEZ JEFFRY Subject LD: !.206 418 141 12. B:l1d 13.CTNS 14 Medra Alert D Yes Iii No No (Explain) 3.\-,(\try ex otizenstip HONDURAS 5. Date Apprehended May 9, 2018 ER/CF HONDURAS Date� Yes ( 8q:iain) TO FROM 15. TRANSFER DAlE Event No: fb\(7)(E\ l4A. A B •• 16. ADMITTED BY: 19. RELEASED TO: 17. SEAROiED IN BY: 20. REI.EASED BY: 18. DATE .ADMITTED: 21. DATE RB.EASED: 24. Remarks: Subject ID FORM !·385 (08/01/07) 1 ... 1 22. Rt Index Print- In b)(?)(E) ALIEN BOOKING RECORD !TEDSTATESDEPARThtENTOFHOMEI.A DSECURITY ·- 2020-ICLl-00006 1079 . ,, 23. Rt Index Print- Qt SIGMA Event, l(b)(7)(E) Subject ID -fo)(?)(E) ORDER TO DETA1N OR RELEASE ALffiN TO: (NAME and TITLE of Person In Charge of Facility) , (Name of Facility) Please � Detain u Release Date Name CX Alien Roy Ale.Xander HERNANDEZ RODRIGUEZ AKA: HERNANDEZ, JEFREN RODRIGUBZ1 HERNANDEZ, JEFFRY I HERNANDEZ, JEFREN; HERNANDEZ-RODRIGUEZ, JEIFRI ; Age 33 I Ulil!PN"!iNT\'R'1.- unni:>T r.?:fTR'7. Date of Birth(Mo.Day.Yr.) 02/18/1985 Subject ID , l(b}(7}(E) Sex M Nature of Proceedings ER/CF HONDURAS REMARKS: I I .TRTV'DT Za.T.RY!.NT\1:?� HONDURAS I Jl�RNI.Nn'll'1.- P("liT\RTf.lll�7. � Nationality I V�IJ,::;t'DT Foreign Address FIie Number A206 418 141 Event No: 11h1n11�1 ignature of Officer Receiving Alien � I - I ' FIN 17851616 ,, TECS REVEALED NO NCIC WAR.RANTS Signature of Off (b}(6}; (b)(7}(C) bl(6l: (bl(?)/Cl I Fonn 1-203 (Re Title CBP OFFICBR -· .. -·- ., Office SND/SYS NITED TATES DEPARTME('ITOF HOMELAND SECURITY 2020-ICLl-00006 1080 I Time Page 1081 Withheld pursuant to exemption (b )(3):Unspecified Statute of the Freedom of Information and Privacy Act Page 1082 Withheld pursuant to exemption (b )(3):Unspecified Statute of the Freedom of Information and Privacy Act 05-30-12;J9:23�M; P .0. Bex 6482 Superior Ambulance Service, Inc. Albuqu,;1rque, New Mexico 87197 506-247-8840 S0S-a30-1260 Fax Fax To: Attn: (b)(6); /h\/7\/r.\ Phone: f'ax: 866-773-7206 □ Urgent □ For�eview From: l(b)(6); Phone: 505-836 (b)(6); /h\171/rl Date: 05/30/2018 /h\(7\/rl Pages: □ Please Comment □ Please Reply □ Please Recycle • Comments: COPY PER YOUR REQUEST CONFIDENTIALl1Y NOTICE: THE OOCUMl:.NTS ACCOMPANYING Tl11S TELECOPY TRANSMISSION CONTAIN CONFIOENrlAL INFORMATION BELONGING TO THE S!;NOER Tl-lAT IS LEGALi.Y PRIVILl:Cl:D. llilS INFORMATION IS INTENDED ONLY FOR THE USE 0� Tl1E INDI\IIDUAL OR l;NT\li' NAMl;D AB� THE AUTHORtzEC RECIPIEN'I' OF nil$ INi:oo/MTION IS PROHIBITED FROM DISCLOSING Tl·tlS INFORMATION TO At-N QTI-!ER PAITTY AND IS REQUIRED TO 0€mOY Tr-IE INmRMATIQN AFTER ITS STATI;O NEEO HAS BEEN FULFILLED. UNLESS OTI-iERWISE REQUIRED BY STATE LAW. IF YOU ARE NOT THE IWrENDED RECIPIENT, YOU ARE HEREBY NOTIFIEO Tt,AT ANY DISCLOSURE. COPYING, OISTRIEIUTION, OR ACTION TAKEN IN RELl.4.NCE ON TI-iE CONTI:NTS OF THESE COCUMENTS IS STRIC'n..Y PROHIBITED. IF YOU HAVE RECEIVED THIS T8-E.COPY IN ERROR, PLEASE NOTIFY THE; SENDER IMMEO�Ta.Y TO AAAANGE: FOR RETURN OF IBESE DOCUMENTS, 2020-ICLl-00006 1083 05-30-12;J9:23�M; Dlltf': M2.y 17, Z018 4 Disp.'!tch #: rb\/6\ Patient N11me: JEFFERY HERNANDEZ PCRN: Response#: I B6-ZOZ7 Response Status: Name: JEFFERY HERNANDEZ I Gender: Mille Weight: 95 Pounds Rec. Med, Rec#: PCR.Author; Provider: Unit#: j D3te of Birth: 02/18/1985 PT HAS NO COMPLAINTS Age: JJ Years Family Physlci11n: Address 1: Addreu 2: ·, City, ST, Zip: Latttude; No Lights or Sirens Mode from SCl!M: Trnnsportlng Unit: Ord./Ref. Doctor: Department! 3101 Loaded MIieage: st.. ri;Jns: Ending: Semi•fowlers Pat. Condition at �ti nation: : : tl�:.:.,:-:'.�!t�liiil�i;,•;)t{::rior to ,his unit's EMS Care: No I Performed By: - Assessment-Adu1t Ye!i None EMS Provider --w--------------------------------------•-•-•-•-•--------•-------���------------- -----�����-��-------•-•-- comment: rime: Attendant: BP M,�:i:hod : Sp02: 22:04:00, Thursday, May 17, 2018 Other Healthcare, Provider Manua1 cuff 96 A1ert 0 Regu1 ar AVPU: Pain $Cale: Puls� Quality: �lec,:ronic Monitor Rate: Resp. Quality: remp: - I Normal e.vent: Vi "ta7 Sig11 Assessment Taken Prior to this unit's EMS care: NO SBP/DEIP: 99/69 CO2 Leve1: Place, Dateir"ime, Person, Event oriented: Pulse: 80 Pu1se Location: Radial Msp,: 18 Glucose: ECG Rhythm: ----------------------�-��--------------------------------------------------------------------------------- GCS - e.ye: GCS GCS c;cs (KS - Verbal: Motor: Tot.a1: QUal if'ier: 4 = Opens eyes spontaneousl 5 m oriented and appropriate speec� Obeys commands with appropriate mo,:or responses lS Initial GCS has 1egitimate va1ues without. interventions such as int1,1bation and sedation 6 ■ ---------------------------------------�-------------------------------- ----------����-------------�------ - RTS: 12 -•-•------•---•-•------------------------------- •---------- ----------•---•----- ---u---����----------��----- Comment: 22:04:00, Thursday. May l7, 2018 Timi!: Ai:tendant l: other He.al th care , Provider Number of Attempts: l Response: unchanged size of Equipment: �utho ri :.:ati on! Protocol (Standing Order) Performed -'ri or to this unit's �MS care: Ni:J Event: Procedure Performed Procedure: BIO-HAZARD/UNIV PRE-CAUTION successful: Yes Quantity: complications: None Physician: '-4 Performed By: E. 5 ?rovider --------------------------���----- ---------��-��-�-�,�--- -------------------------------------------------- Comment.: Time: Time: Time: Time: Time: Time: Time: 22:04:00, Thursday, May 17, 2018 - Event.: At Scene 1'ime 22:04:00, Thursday, May 17, 2018, - Event: rri spatcl'led Time 22:04:00, Thursday, May 17, 2018 - Event: call Time 22:04:00, 22:12:00, 22:J.S:OO, 22:29:00, Thursday, Thursday, Thursday, Thursday, May May May May 17, 17, 17, 17, 2018 2018 2018 2018 - - EVi!nt: PSAP (Public safe,:y A11swerin� f'Qint) Tirne Event:: Leave scene Time EVi!nt:: At oestin�tion Time EVi!nt: :rn servi�e Tiille 2020-ICLl-00006 1085 3/ 4 05-30-12;J9:23�M; 4/ Pag�: ] of] Dl'lt@: /My 17, ZOi 8 Re§pOn�e #: 18-05-86-0038 D1spatch #: fh\/R\· I Patltont Name:.;..""'JcrFERY Hl;RNANDEZ SSN: ls�Ul'd On: 05/18/2018 ..;.;.. 1- - - - - - --..;.;......;.;.;..__....;;.;a.....________ _ _ _ _ _ ,... _ _ _ """"" - ---, ,- _ _____----1 P , � # : a6 202 7 Re s p ons e S at tu s : c om pl et e 05: 33: 1◄ Crt!'WMember (b)(6); (b)(?)(C) I Other Hezilthcare jOther Healthcare, Provider Crew Members Full Namto I Role Dr1ver Primary Pat1ent Caregiver Other I PCR Crr,,,, Signature1 - Sign, Date! 05117/2018 Signatures Driver Atteridant Other 1-1,y"'ll"";l-.lilllttho--t ......... ,.,,,,,....... _, ... _altll­ ':mtrnit• IW!dllll!Mn:ll"l::IPllf'IMl,Wa,.ld,'ll"Ut.tt.11.a�, Dnver: l/b\/6\; /b\/7\/C\ Title: Dr1ver \ EMT-Ba�1c I ReceMng Fac1l1ty Medlc<1l Professional: Title: 2020-ICLl-00006 1086 Typt> 4 05/25/2018 16:49 From: General Hospital, Inc. S\f #s20 r.0011os7 tJl --� [50.,;,1S:--1�-.\b ' w"w.,1h,,[c,l10�pit.lLrn111 \�� FAX COVER SHEET Health Information Management Department Phone: 505-287-5249 Fax: 505-287-5296 CONFIDENTIAL INFORMATION ATTACHED DATE: _s-r/_2____ s�/--4-l__._�...__- TIME: 6 TO: _..... r_)< _);_(b_)(7-)(_C)__ 1 ______ FAX# �_4_C/_q_. REGARDING: _____ j''-i{)p VY) :a..o��11a-lMe TEL# _____ _t>_'3__,,(""'-)______ ; {7_)_(C_) -----FROM:_____.._j(b_)(_6)_(b_) # OF PAGES INCLUDING COVER SHEET: �n -------\..J f ** ** IF YOU HAVE RECEIVED THIS FAX lN ERROR, CALL US IMMEDIATELY AT 505-287-5249*** Mission Statement: To provide excellent healthcare that our community is proud of by committing to: Service, Quality, People, Finance, Growth Vision Statement: To eam your trust and be the first choice for your healthcare CONFIDl!NTIALITY NOTICE: This fax, including any attachment is confidential and may contain protected patient information that Is confidential and prohibited from disclosure under HIPAA and state medlcal records confidentiality laws, or privileged Information protected by peer review prlvllege or other privilege. State and Federal Law prohibits further disclosure of such information without the specific written authorization of the person to whom such information pertains, or as otherwise permitted by State and for Federal Law. If you are not the intended recipient of this fax, or have received It in error, please contact the sender and destl'oy the fax. Thank you. 2020-ICLl-00006 1087 From: 05/25/2018 . ", "�'f"'"" • , .,, l(b)(6); (b)(7)(C) CDR, USPHS f\11\N! \,I;) \ 1 ;Jl).llO /;Jl111ll 16:50 #520 P.UU;.!/V<> r 10:50 05125/18 ET Pg 1-3 [ RN, B5N,CCHP ICE Health Service Corps Field Medical Coordinator- El Paso El Paso Field Office 11541 Montana Ave, Suite£ El Paso, TX 79936 915-856 (b)(6); Office 202-809 (b)(7)( obile 866-773-7206 Secure Fax J(b)(6); (b)(7)(C) Wat ent is UNCLASSIFIE0//FOR OFFICIAL USE ONLY (U//FOUO). It contains information that may be of Information Act (5 U.S.C. 552}. It is to be controlled, stored, handled, exempt from public release un lating to FOUO information and is not to be transmitted, distributed, and disposed of in accordance w, roval of an released to the public or other personnel who do not have a valid "need-to-know w1 authorized DHS official. No portion of this report should be furnished to the media, either ln written or verba o 2020-ICLl-00006 1088 05/25/2018 From: 16:50 #520 P.003/057 18:50 05/25/18 ET Pg 2-3 U.S. !'lepi>rtmflnt of Homeland Sl-'rnritv SOO 12th Street. '5W Wa,hington, D.C. 205�6 FAXTrans,nittal Cover Page TO: Jf'AX: 505-287-5296 CIBOLA GENERAL HOSPITAL ATTENTION: MEDICAL RECORDS ltb)(6}: lb)(7)/C) CDR, USPHS FIELD MEDICAL COORDINATOR ICE HEALTH SERVICE CORPS Office: 91S-856�\�1�hJ Cell: 202-809-fb)(5lj DATE: page FAX: 866-773-7206 PAGE(S): 2, including cover 05-25-2018 REQUESTED FOR FULL COPY OJ:• MEDICAL RECORDS 2020-ICLl-00006 1089 " ' " ' """' '" ' " From: 05/25/201B 16:51 ··-· ·- --· ......;JV•- #520 P.004/057 10:50 00/25118 ET Pg 3-3 -�·••w'f\A\.h.l" '"'' 1,0""•� ,1\JWLor-.1L�I ()[fine uf 1:1:fo,u,mF.nt a;ld Hr!IIWY,JIOp .1JfiOl15 U.S. Oepartm�nl of Homel,;nd Security soo 12th Street. SW W;,shineton. u.C.. 20535 Date: May 25, 2018 MEMORA DUM FOR: Cibola County Correctional Center 2000 Cibola Loop Milan, New Mex:ico 87021 FROM: SUBJECT: fb)(6); (b)(7)(C) CDR, United States Public Health Service Field Medical Coordinator ICE ERO Field Office·· El Paso Release of Information This is an official request for the full and complete medical record on the helow rcF. detainee. • Detainee Name: Hernandez, Jeff ry • Detainee A# 206418141 • DOB : 02/18/1985 • Applicable dates of health care: May 20 l 8 ICE Detainees are not subject to HIPAA based on the below standards: Disclosures for law enforcement purposes are pennitted to respond to a request/or PHI by a correctional i11stit1.1lion or a law enforcement official having lawfal custody of an inmate or others if they represent such PHI is needed to provide health care to the individual_; for the health and safety of the individual, other inmates, officers or employees of or others at a correctional institution or responsible for the transporting or transferring inmates; or for the administration and maintenance of the safety, security, and good order of the correctional facility, including law enforcement on the premises of the facility (45 CFR 164.512(k.)(5)(i)). A covered health care provider may, without consent, use or disclose protected health infonnation to carry out treatment, provide payment, or perfonn health care operations, if: The covered health care provider created or received the protected health infonnation in the course of providing health care to an individual who is an inmate (45 CFR 164.506(a) (2) (ii)). Please send the complete medical record via fax. to 866-773. 7206 �b)(6); (b)(7)(C) I Please do not hesitate to contact me at 202-809-1(b)(6 llifyou have any questions. 2020-ICLl-00006 1090 or email #520 r.uu�1u<>1 05/25/2018 16:51 From: 1�PATE'NTACC9Um'NUt-'B!R ::1 , I P"ATIENTINiii'rie;Addiesii;•Plion_ll_�':· _· -•�·' · '"� · ,... · 4499030 HERNANDEZ JEFFRY 2000 CIBOU. LOOP MILAN m '. I· i', MS:", : .: .' •:·} AGE ... [, csmr;• T'RACE .._:e_R-'THDA.TEi•; · ' ..... '' .c... NM 87021 , !"116-1n-,-- csos) ns -4soo Pl'Tff=l'JT E,m,t;OY:ffl/�me Add-.-, UNEMPLOYED :Ml!DICAL:RECORD NUMBER. :. CIBOLA GENERAL HOSPITAL 1016 E. Roose�elt Avenue · Grants, NM 87020 · (5.05) 287--4446 000000000 02/18i 1- 985 "1·· . . 000166116 ETHNICi:t P.ATIEITT SSN.·ac 1 .......,.,.,,... -= ""'" Dl"""R-.-.-.,.,··,.;· · · Q A-N ce:= ,:-Af) .,...�::""' '/FORMERcNAME/-AK;A :·_:: _· ; , :"''·-• · :· '·HSY'" : •i'REL:� -MAIDfN:'NAMf 0 �T-OATE,& llME. -: • -·r 0AT�_Of,LASTVl$JT: . · .· ·,iro:�eo : . I• ADM CLfRK _ Jl . •1'.. I" . · , W .. ,· , � --- 1 j 0;;17 ;1a 11, 59 :;;;. :::ai;'.°.., . :·,""':: ;;.';;pho ...":i'fl>« · , .i'. ii...· r, i1° ,ini ,,rai=.11UAii'M. i"w�, t,(,IJI d"IIONB: (999)999·9999 s �DENTDAl£·..· :1,itcetDEN1 :HOUR .-� NM 87021 HOME: (505) 285 · 49 00 1,10R1<, PHONE: ,:oooi � 2 ··-�5$U1US': :IOM.E, RET,: 24 WORK, I · .,t i! REL: (000) 05/11 /18 oo_\W7ii:mm;.;;;.-� . .1 ·1 fl!!""• DAT�&11Mi! : 21, 35 J . ; .. !..J..2: CORPS IC!:: HEALTH SeR"JICB -----· INSURED'SNAMi! . IUUIIE Of ...,...,.II.NC£ ! TElEPl40�" NUMB E� ( AC""-"ff PAT REL TIONNO l'OUCV NUIIUIEft N�BEI! . PAT INSUI\EO'S REL: y : ADM.lTTING DIAGN0$1$ l.c.-tef QQMPcl;AJl.n: : :· FEVER, UNSPECIFlED L_ •• 00014499030 CC1020 EL , .- ---- . · -- - · · 1 NONE LOCAL ------------- ------ ------,c:c= ADNI 8 lll01f9 Dl ll Ill lllllllllllllllOIIIIHlllll In HI 0111/IIIRlllllll Ill 05/17/lB 000166116 B!:RNANDBZ .n!:PPRY 2020-ICLl-00006 1091 J l QlOl 1Zl011 0 3 Cibola General Hospital EMERGENCY FLOW SHEET RECORD Name: HERNANDEZ' JEFFRY A.ge: 33Y MR : 166116 A cc: t 4499030 VlTALSIGNS TIME BP MAP PULSE RESP TEMP PAIN 02SAT END-TIDAL CO2 VITAL SIGNS TIME BP MAP PULSE RESP TEMP PAIN 02SAT b)(6): I 5/17/2018 20:00 80/52 61 92 17 96 lb)(6): I 5/17/2018 18:15 86/59 68 TIME BP 85/54 64 RESP TEMP 22 PULSE PAIN 02SAT END-TIDAL CO2 110 66 97 11 67 106 6 96 98 100 0 l(b)(6); I 5/17/2018 18:00 81/51 18 I 83/58 kb)(6); I 5/17/2018 l 7:45 84/48 60 173 92 (b){6); I 5/17/20L8 16:45 (b)(6); 87/60 69 l32 36 5/17/2018 19:15 86/58 lb)(6), b)(7)(C) 5/17/2018 18:30 91/66 74 I 106 0 95 lb)(6); I 5/17/2018 17:30 81149 59 17 18 96on lfff1..ml8 17:15 81/50 60 104 20 92 1 5/17/2018 16:30 IOl.l 'jb)(6): I 5/17/2018 16:30 90/60 70 131 32 (b)(6l: I 5/17/2018 16:15 86/65 72 122 33 \mtr.\ I Stanis: Active. TYPE AND SCREEN: Ordered by: !(b)(6): (b)(7)(C) Ordered for: !Cb)(6l: Cb)C7)(Cl Status: Done by: System - Thu May 17, 2018 17:02. ABDOMEN 2 VIEW: Ordered b : fh\/n\· lh\/7\IC:\ y Ordered for: Kb)(6); (b)(7)(C) j PARTIAL THRO,\fBJN TIME: I I I I I f l I Status: Done by: System - Thu May 17, 2018 15:40 Reason: Abdominal pain. CHEST 2 VIEWS: Ordered by: fh)lfll· lhlmlC:l Ordered for:kbll6t /blf7\ICl Status: Done by: System··· Thu May 17, 2018 15:40 Reason: Cough, fever. CTA CHEST WI: Ordered by: k'hllfll· lhll7llC:\ 1 Ordered for:!(b\16\: lb\(7)/C\ Status: Done by: System - Thu May l 7 2018 17: I I Reason: Elevated D-dimer / hypoxemia. RAPID HIV: Ordered by: (b)(6); (b)(7 (C) Ordered for: \/6\: lb\ IC\ I l I Status: Done by: System -Thu May 17, 2018 17:45. Ordered b. )(6); (b)(7)(C) Ordered for: ..._______. TSII: Page: 2 of 17 2020-ICLl-00006 1096 05/25/2018 16:54 From: #520 P.011/057 HER;"iANDEZ JEFFRY DOB: 2/18!19R5 M33 Wt/Ht: MedRec: 166116 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Status: Done by: System -Thu May 17,2018 18: 16. ALLERGY No Know11 Drng Allergies IMAGING RADIOLOGY: Image captured from scanner. Page 2 added. Image captured from scanner. EKG: Jmage captured from scanner. CONSENTS: Image captured from scanner. TRANSFERDOCUMENTS: Image captured from scanner. Page 2 added. Image captured from scanner. CORRESPONDENCE: Image caprured from scanner. Page 2 added. Image captured from scanner. Page 3 added. Image captured from scanner. Page 4 added. Image captured from scanner. Page 5 added. Image captured from scanner. Page 6 added. [mage captured from scanner. Page 7 added. Image captured from scanner. Page 8 added. Image captured from scanner. MEDICATION SERVICE oce1ami11ophen oral: Order: acetaminophen oral 325 mg - Dose: 650 mg Route: Oral Ordered by: (b)(6J; (b)(7)(C) Thu May 17, 2018 15 :49 Entered by: Acknowledged by: kb)C6Ub\(7l/C\ tfhu May 17, 2018 16:46 Documented as given by:k§1r6t (b)(7)(C) jl'hu May 17, 2018 15:50 Patient, Medication, Dose, Route, Schedule verified prior to administration., Amount given: 650mg, Correct patient., time, route, dose and medication confinncd prior lo administration, P;itient advised of actions and side-em..'1.,-ts prior to administration, Allergies confim1ed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside, Given by kb)(6); azithromycin intravenous: Order: azitltromycin intravcnmL'l 500 mg - Dose: 500 mg Route: IV Piggy Back Ordered by: (b)(6); (b)(7)(C) Enteredby: ·huMayl7,201817:51 Acknowledged by:!(b)(6); (b)(7)(C) lrhu May 17, 2018 17:52 Documented as given by: kbl<6)' (blmCCl !Thu May 17, 2018 18:08 Patient, Medication, Dose, Route, Schedule verified prior to administration., IV SITE# I TVPB or drip, subsequent infusion, IVPB mixed in: 250ml, Fluid: 0.9NS, via primary tubing, on an rv pump, Connections checked prior to ad.ministration, Line traced prior to administration, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, JV flushed after administra1ion, Correct patient, time, route, dose and medication confiTilled prior 10 administration, Patient advised of actions and side-effects prior to administration, Allergies confinned and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position : Follow Up: _IV SJTE /II:_, infusion done. famotidlne (PF): Order: famotidine (PF) 20 mg/2 mL - Dose: 20 mg Route: IV Push Ordered by: (b)(6); (b)(7)(C) Entered by: hu May 17,201812:26 Acknowledged by: !(b)(6), (b)(7)(C) fhu Mny 17, 2018 13:08 Documented as given by:j(b)/6). (b)(7)(Cl t Thu May 17, 2018 13:37 RN. I Page: 3 of l 7 2020-ICLl-00006 1097 0 5 /2 5 / 2 018 16:55 From: # 5 20 P . 0 12 / 0 5 7 HERNANDEZ, JEFFRY DOB: 2/1 8/ 1 985 M33 WVHt MedRec: l 661 1 6 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Patient, Medication, Dose, Route, Schedule verified prior to administration., IV SITE # I !VP, initial medication. S lowl y, Slowly, Connections checked prior to administration, Linc traced prior to admin istration, Catheter placement confinned via flush prior 10 administration, TV site without signs or symptoms of infi l tration durin g medication administration, No swel ling during administration, !-.'o drainage during administration, IV flushed after administration, Correct patient, time, route, dOt>'e and medication confinned prior to administration, Patient advised of actions and side-effects prior to administration, A llergies confirmed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position. Rocephin injection: Order: Rocephin inj ectio11 I gram - Dose: I gram(s) Route: IV Piggy Back �-=-...,,..,.'='"'� Ordered by : (b)(6); (b)(7)(C) Thu May 1 7, 20 1 8 1 3: 5 1 Entered by : Acknowledged by: j(bl(6): (b)(7)(Cl !Thu M ay 1 7, 2 0 1 8 1 4 : 1 8 Documented as given by : llh\/R\ lh\17\IC:\ ! Thu May 1 7, 20 1 8 1 5 : 3 7 Patient, Medication, Dose, Route, Schedule verified prior to administration ., Amount given : I g , I V SITE tl l IVP B o r drip, initial infu.sion, IVPB mixed in: 50ml, fluid: 0.9NS, on a n IV pump, v i a secondary tubing, Connections checked prior to administration, Line traced prior to administration, Catheter p lacement confinneu via flush p rior to administration, JV site without signs or symp toms of infiltration during medication administration, No swelling during administration , No drainage during administration, IV flushed a{kr administration, Correct patient, time, route, dose and medication con fimied prior to administration Patient advised of actions and side-·etfect� prior to administration, Allergies confumed and medications reviewed prior to administration, Patient in p osition of comfort, Side rails up , Cart in lowest position. : Follow Up : No signs or symptoms of allergic reaction noted. _ fV SITE # I :_, Medication infusion discontinued. on Thu May 1 7, 20 1 8 1 6:00, Total amount infused: 50, Advised not to ambulate without assistance, Patient in position of comfort, Side rails u p, Cart in lowest position, Famil y at bedside. sodium chloride 0. 45 % intravenous: Order: sodium chloride 0.45 % intravenous 0.45 % : [ 1 000 mL(s)] - Dose: 1 000 ruL Route: IV Fluid Notes : 1 000 cc/hour Ordered by : b)(6); (b)(7)(C) Entered by: Thu M ay 1 7, 20 1 8 1 7:55 Documented as given by : �b\(6\: (b\(7\(Cl lrhu May 1 7, 20 1 8 1 8 :06 Patien.t, Medication, Dose, Route, Sch edule verified prior to administration., JV SITE # I IV fluids established, IV SITE #I 5th bag hung , amount I Liter, JV SITE # 1 bolus of 1 000 m1 established, IV SITE # I Rate of bolus, 999 . ml/hr, via primary rubing, IV SITE # I on IV pump , Connections checked prior to administration, Line traced prior to adminisrration, Catheter placement confinned vi a flush prior to administration, IV site without sign.� or symptoms of in filtration during medication adm inistration, No swellin g duri ng administration, No drainage duri ng administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration. Allergies confirmed and medications reviewed prior to administratio11, Patient in p osition of comfort, Side rails up, Cart in lowest po sition. : Follow Up : _IV SITE # 1 :_, remainder sent with pt and fli ght crew. : Follow Up : _IV SITE tfl :_, remainder sent with pt and flight crew. sodium chloride 0. 45 % intravenous: Order: sodium chloride 0.45 % intravenous 0.45 % : ( 1000 mL(s)] - Dose: 1 000 ml Route: lV Fluid Notes: With 20 mE KCL per L at 500 cc/hour, 2nd JV site Ordered by : b)(6); (b)(7)(C) F.ntered by : 1,----..,.---' Thu May 1 7, 20 1 8 1 7 : 56 Documented as given by : iiblfR\· 1h\m1r., ! Thu May l 7, 20 1 8 1 8:08 Patient, Medication, Dose, Route, Schedule verified prior to administration., JV SITE # I JV fluids establ ished, IV SITE # I 6th bag hung , amom1t I Liter.. rY SITE #1 bo l us of 1 000 ml establis hed, IV SITE flt Ralc of bolus, SOO ml/hr, SITE #I on IV pump, Connccu ons checked prior to administration, Linc !raced prior to administration, Catheter p lacement confinned via flush prior to administration, IV site rv Page: 4 of 17 2020-I CLl -00006 1 098 0 5 / 2 5 / 2 0 1B 16 : 5 6 From: # 520 P. 0 13 / 0 5 7 IIBRN A NDF.Z, JEFFRY DOB: 2/1 8/1985 M33 WtlJ-l.t: MedRec: 1 66 ! 1 6 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD without signs or symptoms of infiltration during medication administration, No swelling during admini stration, No drainage during administration, IV flushed after administration, Correct parient, time, route, dose and medication confimted prior lo administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside. sodium chloride 0. 9 % intravenous: Order: sodium chloride 0.9 % intravenous 0.9 % Dose : 1 000 m L Route: JV Fluid Notes: 1 000 cc per hour Ordered by: {b)(6); (b)(7)(C) Entered by: hu May 1 7, 20 1 8 1 2 : 2 6 Acknowledged by fb)(6): (b)(?)(C) Thu May 1 7, 20 1 8 1 3 :08 Documented as given by: ft>J/6}. /blC7l/Cl {Thu May 1 7, 201 8 1 3:37 Patient, Medication, Dose, Route, Schedule verified prior to administration ., TV SITE #1 IV fluid.c; established, IV SITE # I I st bag hung, amount l liter, JV S ITE # I bolus of 1 000 ml established TV SITE # I Rate of bolus wide open, via primary tubing, Connections checked prior to administration, Line traced prior to administration, Catheter placement confinned via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No �wel!ing during administration, No drainage during administration, rv flushed after administration, Correct patient, time, route, dose and medication confinned prior to admioistration, Patient advised of actions and side-effects prior to administration, Allergies confinncd and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position. : Follow Up : No signs or symptom s of allergic reaction noted, _IV SITE # I :_, JV fluid infusion discontinued, on Thu May 1 7, 20 1 8 1 4:40, Total amount infused: 1 000, Advised not to ambulate without assistance, Patient in position of comfort, Side rails up, Can in lowest position, Family al bedside. sodium chloride 0. 9 % intravenous: Order: sodium chloride 0. 9 % intravenous 0. 9 % Dose: 1 000 ml. Route : t V Fluid Notes: 1 000 cc per hour, 2nd JV site Ordered by: b)(6); (b)(7)(C) hu May 17, 20 1 8 1 3 : 54 Entered by: Documented as given by: l(b)(6); {b)(?)(C) Thu May J 7, 20 1 8 1 4 : 1 7 Patient, Medication, Dose, Route, Schedule verified prior t o administration. , I V SITE # I l V fluids established, IV SITE # I 2nd bag bung, amount l Liter, IV SITE # I bolus of I 000 ml established, IV SITE Il l Rate of bolus, wide open, via primary tubing, Connection s checked prior to administration, Line traced prior to administration, Catheter placement confirmed via flush prior to administration, IV �ite without signs or symptoms of infiltration during medication administration, o swelling during admi n istration, No drainage during administration, IV flushed after admrn istration, Correct patient, time, route, dose and medication con finned prior to admin istration, Patient advised of actions and side-effects prior to administration, Allergies confinned and medications reviewed prior to administration Patient in position ofe-0mfon, Side rails up, Cart in lowest position. : Follow Up : No signs or symptoms of allergic reaction noted, _I V SITE # I :_, JV fluid infusion discontinued, on Thu May 1 7, 20 1 8 1 5 : 1 7 Total amount in fused : 1000, Advised not to ambulate without asi.--istance, Patient in position of comfort, Side rails up, Cart in lowest position. sodium chloride 0. 9 % intravenous: Order: sodium chloride 0. 9 % intravenous 0. 9 % Dose: l 000 mL Route: IV Fluid otes: l 000 cc per hour, I st IV site Ordered by: (b)(6); (b)(?)(C) Thu May 1 7, 20 1 8 1 5 : 1 7 Entered by: Acknowledged by: l(b){6), {b)(?)(C) Jrhu May 1 7 , 20 1 8 I S :20 Documented as given hY!(b)(6): (b)(7)(C) !Thu May 1 7, 20 1 8 1 5 : 3 6 Patient, Medication, Dose, Route, Schedule verified prior t o adm inistration., IV SITE # I IV fluids established, I V SITE # I 3rd bag hung, amowrt 1 Liter, IV SITE #l bolus of 1 000 ml established, IV S ITE II 1 on IV pump, Connections checked prior to administration, Linc traced prior to administration, Catheter plac.ement cunfinned via flush prior to administration, IV site without signs or l'iymptoms of I l ?age: 5 of 1 7 2020-ICLl-00006 1 099 06/25/2018 16:57 From: Rs20 r.0141067 HERNANDEZ, JEFFRY DOB: 2/18/1985 M33 Wt/Ht: MedRec: 1661 16 AcctNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confinned prior to administration, Patient advised of actions and side-effects prior to administration. Allergies confirmed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest posilion. : Follow Up: _IV SITE #1:_, rv fluid infusion discontinued, on Thu May 17,2018 16:40, Total amount infused: 1800, Advised not to ambulate without assistance, Patient in position of comfort, Side rails up, Cart in lowest position. sodium chloride 0.9 % intra,,,mous: Order: sodium chloride 0.9 % intravenous 0.9 % Dose: 1000 mL Roule: IV Fluid Notes: 1000 cc per hour, 2nd IV site Ordered by: (b)(6); (b)(l){C) Entered by: Thu May 17, 201815:17 Acknowledged by: Kb)(6); (b)(7)(C) trhu May 17, 2018 15:20 Documented as given by:!(b)(6);(b)(7)(C) !Thu May J 7, 2018 15:36 Patient., Medication, Dos-c, Route, Schedule verified prior lo administration., A mount given: l L, rv SITE #2, IV fluids established, 4th bag hung, amount 1 Liter, JV bolus of 1000 ml established, via primaiy ruhing, on IV pump, Connections checked prior to administration, Line traced prior to administration. Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confinned and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position. : Follow Up: No signs or symptoms of allergic reaction noted, _TV SITE #2:_, lV fluid infusion discontinued, on Thu .\fay 17, 2018 16:40, Total amount infused: 1000, Advised not to ambulate without assistance, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside. PRESCRIPTION No recorded prescriptions RESULTS RADIOLOGY: ABDOMEN 2 V JEW Observe DT: Thu May 17, 2018 J 4 :0 I , ABD2 CIBOLA GENERAL HOSPITAL Radiology Department GRA TS, NM 87020 1-505-287-5250 RADIOLOGY RF.PORT Pt. Name: HERNANDEZ, JEFFRY Referring Physician: Jacket#: 166116 DOB: 2/18/1985 ..,_ kh.,_,,l/.,_,Rl.....,_,_ lh:.::.lf.,_ 7\... 1r."".,______ Pl Type: 0 Rm#: Sex: M Exam Dt: 5/17/2018 MRN: 166116 PROCEDURE: PA AND LATERAL CHEST RADIOGRAPH INDICATION: Cough, fever, headache, abdominal pain x5 months COMPARJSON: None. FrNDJJ\GS: The lungs are well aerated. No focal l:onsolidation, edema, pneumothorax or pleural effusion. The cardiac silhouette is within nonnal limits. The visualized osseous structures are unremarkable. IMPRESSION: Page: 6 of 17 2020-ICLl-00006 1100 #520 P.015/057 05/25/2018 16:57 From: HERNANDEZ, JEFFRY DOB: 2/18/1985 M33 Wt/Ht: MedRec: 166116 AcclNum: 4499030 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Nonnal chest radiograph. PROCEDCRE: SUPINE AND UPRIGHT ABDOMEN RADIOGRAPH JNDTCATIOl\': Cough, fever, headache, abdominal pain x5 months COMPARISON: None FINDINGS: There is a nonobstructive bowel gas pattern . Large quantity of small and large bowel gas is seen in the mid ·upper abdomen. No free intrapcritoneal air on erect view. The visualized osseous structures arc unremarkable. IMPRESSION: No radiographic evidence of small bowel obstruction. Large quantity of small and large bowel gas is seen in the mid upper abdomen. INTERPRETED AND ELECTRONICALLY SIGNED BY: l(b)(6): (bl(7)(Cl at 03:34 PM RELEASED BY: 85 on 05/17/2018 at 03:37 PM TNTERPRETED and ELECTRONJCALLY SIGNED BY: !T: Thu Mnv 17, 2018 13:06 TROPI Measurement LIPASE Collection OT: Thu May 17. 2018 13:06 LIPASt: KuuJI Unit, Ran2e <0.017 n£/mL 0.000--0.056 Result Uoll• Rall1!e S27-H VIL 73-393 Measurement Result UnltJ Ranl!t CK 14 - L IU/L 39-308 R�_u_lt /Urllts Ru1e 114 llU/L is-ns CK TOTAL Collection OT:ThuMav 17 2018 13:06 i Measurement I AMYLASE C.oll30 mi/dL OidL 46 ll6 14-67 15-37 0.2-l.0 6.7-8,2 ·-- RATlO 1.1-J.8 IU/1. 0.5 -· 135-14S 3.6 5.0 100-108 21-31 4-15 8.4-10.2 74-I06 RATlO JOO 17 ALT mmol/L m11/dL 91 ALKALIN c PHOSPHATASE Ranae me:/dL mw'dL 105 26.5 26-H 1.0 GFR Unltt mmoliL mmoVI. mmof/L mmol/L 3.8 98-· L 23.9 12 CRJ-:ATININE I I ! R:ldL Result Units Ranll:t 0.9 mmnlfl. 0.4-2.0 3.2-S.S Page: 8 of 17 2020-ICLl-00006 1102 05/25/2018 16:58 From: #520 P.017/057 HERNANDEZ, JEFFRY DOB: 2/181!985 M33 CIBOLA GENERAL HOSPITAL EMERGENCY RECORD Meuurement WI/Ht: McdRec: 166116 AcctNum: 4499030 Result Uolu Rane:e -·-- -- CBC AUTO DlFF Collection DT: Thu Mav 17, 2018 13:06 See comment below Platelet cvalualion a11:rees with au1omated coum F cw sm udac cells present WBC 5.6 10/3 uL 10 HGB 3.16- L 8.6-L G/dL HCT 15.J- L % 3.6-9.6 4.64-6.00 12.0-16.0 36-48 MCV 80.1 - L 27.2-L fL 81-98 Pl! Gi'dL 27.6-33.J RBC MCH MCHC 33.9 RDW 14.3-H 69-1. 10,7- H PLT MPV M% 156--450 7.4-10.4 fL 0. 7• 33.4 MO% E0"/4 0.2 NE# 0.6 2.4 !YI/ J.9 EO# 1.3-H 0.0 % •·lo 22.9 MO# ll.6-13.7 IO 42.9 LY% BA% 33.0-34.8 % % % l.8-7.0 JO 10 10 10 JO BA# MAN DIFF 0.0 NEUT 42 % BAND LYMP 5 % M0!\"0% 18-H EOS PLTEST 0 YES 35 1.0-3.4 0.2---0.8 0.0-0J 0.0-0.l 40-76 il-5 % 16-47 % % 2-JO 0-5.0 DECREASE Rtsult Mea5u�ment PROTHROMBIN TIME Collection U'! : Thu Mav 17. 2018 l 3:06 PROTHROMBI� TlME INR -- 15.7-H 1:nits Ranl!.C Sewnds 9.8-)4.5 --- Range Tan:et Primary and s cc ondarv prevention of venous 2-3 thrombosis 2.5 Prevention of rec u rtetJ t venoo s thrombosis 3.0 2.5 - 3.5 Prevention of arterial i thrombocmbolism includin� patien t.s with mechanical heart valve, 2.5 - 3.5 3.0 •*" New Prothromhin Time rcfrrcnec ran!!.e effective 2-1-18 • • • INR INR --�- Ran20 \feaJS: 0.358-3.740 u!Ulrnl ... . ·············•·*••*••·········4�•············ ALL TSH VALUES REPRF-SF.NT 3RD , "coitrun:p TOMQGR,Al';HY (CT} PA1"1ENT CONSENT . OUESTIONNAJRE/CONl'RAST � . . hticnt NllllV: ___________ P�t DOB: __ · ____,P_■tiqit Weight; __lbs Oct yw li•vnfiiHow ijp appt. with )")l.•to ind.i.; �-o(a,:l!IP'.0011_; ; I 1· Pl-« n1r uypr:lu·CT -�. MRI tear!,.) UJ"".......i. c..- x.1tnuinal11m1 ta lhi�..!ll\ld�.... . ' Eu111 • · Patt . Loa1'ole I 1 =.:i _j -------.,-n.tr. ,.. · ------ ·1 r:.:==�......,....,.._------+---""--�-✓ medil;lti00$ ft;lt ._Q�n�ins - . � or _S,ckk tell .-· ' . . Wllll't- :• l../, ;,;;' ::::.. �--.......��;· �=::..==�-=��kms ,__.. , _.,. /: ' · ·cmalc Patle�:- Aie .rRd to h""' S ,. Dta.·•·il,u)'lllplllms{'fto1vorso .-.ction,ONa,,,ca Ov,,.,.;lillil .. ... □ Hive• Ooiftlcal)y�,..,.� Ooou ri-�o-,ibe: __ae- ICLl-00006 1113 .. . ... ..... . . .... .. ............. ... .2020- . . . ... . .......... ... ...... ··•·· - --�- ........ . .• From: 05/25/2018 17:05 Rcmenl N;une Fir.st)..____ 8ir1M�: 0� a DI� Nlflllll9IOII �GI se,vtoe, L.-.....· ······---·--·-j llbrlS(!fn-..ap"""'°"'; . lJ c..moc,,- C.,-. °""'��fMMINlon: 0 .Sff C �: IJ Nr� ·0 � a-,...a.:,L_ _. ·---i. -------- J . __J ER Pttysk:lan's Report c� P'lt;-slc!eil s�,_.,, 1 • "r .. •• • � � -•- . � • -�-• D.stl.AN t$OI.PCSI oo NOT inforil'>n'.sid!"nl� Qf1he da(e/1 ime of ic-vltaliufJon,. r-'�;,... • ■ �;: � • '!"'1°• - � � � - � - • - _,_•_, • -_:,... • -� - � -�- > - � '.,_ � • • � r•-� I��.,;.'<:.� - • ; I� j _;,,. � ;;.:, •- • ___. - , ,.... • � �..,. 2020-ICLl-00006 1114 • :ar ■ - • ""' -- - � • - �•.- ; ......-�.7"" �; • . #520 P.026/057 05/25/2018 From: C_O_RRE�T �Jl._RE :SoLUHONS.,' DUVCUCfAN'S ORDERS HfRNANO[Z. JEFfttY np,8: il'l/18/1!!1!5 -M Af!l>: 05/16/}0l.S l:CC:CIMiw.i, R102J. NM OAlf: #520 P.029/057 17:05 tNC; !011: ___ ,__ ." Ali[RGIES-_l,.;;/l-t:.,,u&:..:·----- - ...----------'-------- --,·� f'ttV$1CWC'.S <>MFA ·----------­ -------------,-----·-----------·-··· ------------------�-----1 -----------------· -··----------- ----- ' \ i I .) l. 1-----.,' 2020-ICLl-00006 1115 From: 05/25/2018 17:06 .A rnn1n:r'r i':11.n<: ll'SORDERS A206418141 1-!FRNANO £Z, JCHR¥ DOB; 07/18/l',J� . M A¼l.b: 05/16/l(li8 cc:tCIMJtAN NM s1021 .DATE 10,.: ______ LERGIES:,-LJM:.u�aM�---PHYSICIAN'S OROER i H!V virel loud (to hospitit rontmw) 7 TO Quamclcr� Gold (io iwsp�-11 foi iamw) \ . V11ricolla (09fi205 aiw 096176) Tmc,,iillifT10llitiiD004117S 11iid 0986511 14) MdilroneHabs fQi' HCV+ staru�: , ___,._______________➔�b)(6); (b)(7)(C) 7) V.accif!es.: Jnfli;enza lin <.eJJsonl F neumonia im:c:::sz;:__----,1 /h\/�\­ CCS-CI' ,,I.a ··HepBseties 2020-ICLl-00006 1116 #520 l"'.030/057 05/25/2018 17:07 From: • l , _,' .-6 :coRRECT -CA Rt AlD&418141 . - · · lifRNANOtt, JFFfRY oi 008:0l/18/l!JSS M '-- ARo, OS/16hCm! O/ CC:ct/MilAN, NM �7021 0 �Ir>$�;;,, l!tvicwc:4 ] oa� f'l•me cf l ·· Elco,;:,, - ___,.__I .......,<_· 11" l.£i_, I - F��litr; ··: ________ __?!.�_ola C<:c. JO ;11,,,., A'lerg;..,; (Oru�,/foods/Ct>nlrast): ;..;.:......;:; N�> 117·P;;,i,lem lht Upd-11� __, __________ I o Old 11.ernr!h llequeslt,d Oe:Krlplion ,;,I lr,Jurl-es/�kir, M.11rlcsfrat1-<>cs: -� f-- ,,J;., t-rjJ,ri...,,,I ,;,,l-r _ _,_ - J--,.. .A.� - (b)(6); (bl(?l(Cl I ll"rc ··· / . □ �..liv tMy, kt� tl<>'JJr"fl. food �i,,l;,e tllll Progo,n, a·. r., _NOl _q1111ff1e<1 for ti,.-, fui��I),• �-- ________ ......... -----· Ed"catfon: Prl,n,c <1/lyprd N;mi, ..-f '-"""d�n - 1/h\/'"· PritJt,;rifin,�d ts•;,;• �"r�;f-----'-'�7, "' 1 M□ 0 1.l "' "----- O�t•/Tlrn< �l):lf' l�"!:-o aie/i J,,.,� ------- ... I 2020-ICLl-00006 1118 oop; #520 P.032/057 05/25/2018 17:08 From: ''.;.. :;.:b. � · '·-✓ � U.S. Ixmnign.tion ··.: · · · · · I a.nd tusloms :·: - � · · !�.,$, b•l"tUIO"'"-m�i""4S<>!=l:Y · :�J�ti�.r--�'S\..J V,'Ul_�"!!'C'". O.t. 2C5S6 ,. Enforcement DAT[;; Sc.iu�mhcr l 2, 20 l 3 MBMOltAN!.>U'.,.,t FOR: 17o\-idu5. of Heal.iii. Crui:; Sctvic� h:> Jii:-�n�Tli ii) the Custody of 1ci-: �-�h;m:111cn1 ��11 R(!mov,i! O['lelall°'iS: (ERO) i,nd Hon:1c;!Md �1"it}'. .l1w�qiigatiM� (Hi-:ll). Rordct Pt1ti-ol (B�). ,1r: C�'i/orm; 1md BorderProllX'.llon (CBI') FROM: A11Um1iz.111ioro ror:HeAl.th C�rt: !kl"1/il:cii 1'01 limrug1·iii1fon ;md (��toms hnfurcem¢nL ci'c;i:J Dc1aincet Sl.Hl.lliCT: J('J� llMllh StrVicc Corps (ll-l.Sq Si l'�po1lSib\c'.f0TfAcilit.11ing tilc,r:im!)uP.;emel11 of audtori7..ed -t:c,,hh r:m.1,� .�ervke.� for illClividuiib; in lhe cu�lc}dy nf ICBJ:i1!0tccm�lll fk-m<,>v,11 Opi:,r,uic,n-s (ERO), U.S. Borvided bcahh <;Mc sci·viccs n pmons io titt:-.cu�tody oftbe afoltin�ioJJcd 1111·c.ncios:t�"fflf,nl$':U:l (" pm�i_dr:.r wW, _ll .:up,;• •.,f llu; �PJl(OVl'".'1. !>kdfl AR. m 2020-ICLl-00006 1119 #520 P.033/057 From: . ..: . �.: \ 05/25/2018 17:09 . ·. :No11-emc�e.11t deriu.l �as al� require n paymcnl ;1uthom.1tion pri1w w the mvk.es being . perform�. If futtiiertre�ttnent, which 4 detattjiued to be r.cccSSArY, was not iodrulcd it, the foiti$ .authori:,..adon, a separate jnithorizmiQn Aiid_ visit will be Provideuoromside dent.al s�t'A'JS ::ibowd submil tieut,ncm plan, lht detcnc'iori -fa.cilh)' housing I.be detain-cc (II' {in ili't's whcff, hoosloi; Im yt±. to J:,c, determnlOO) kt �!alms f� ICE/GBPJBPfor IHSC ·- n:Vle;v and approval. Plans sbould ineludc the numbei(s� if applicable. -the elinicni finding, pro�dllrell �tiired, and the _'1COCS51ll)' Curm,t l'et111in.ol(lgf (CD1) l'rcitetcnDinatfon �1imatcs should be provided on fut: current� Association (ADA}faims. :requiicd. fo' tooth Dcnui\ m £kntal Date{s} of�cc required 6n all autborimtim;, ll£11.b � and mergcn1, TTti R((Ull'(fflCnt lillows for efficient cl11ims procw;injl payment for �ice!! re.nliered. appoil\lmenl dale is fot� fmal ..ulhuritJLtklns. The dclti,lion fiici!ity or �)' �Wivt ean pi.uvidie provider with li .oopy ofn per1ding detc:rmi!Wion of a dt.tc of service, However, the dcW:ntiOII facility or �m, will be requ.irM to sumnit the approvoo to the heo.lth can: pnwider, and � ,eqtiin:d Uie lwllth �� An the and piwmi� firinl wthtin..mtin Rnmbut11e1Dc'at Policy Aullrori?M paytnedlS for �111 care kfY:ic-es will be mimbi,,.riicd in aw:irdmce with Title I Part Ill, Cfuqltcr 301, Section 4006 of the U.S. b:m � shall ,wt-� Medic.lire rtimburaeroMt ·rok$ unle$$-exp1i1-itly wi11 make� for 1�rvjcc;1 tfuootly w tne bcellh we pro� of aSCJVi«:$, ra_ymmt for domied sc.-vi� i�-aubjool -m custody Vl!l'ifiattim. llll1horlc4i. JRSC tha!ie Denial $,el'Viccs 11ft' rcimbun,,ed at ibi:: � JC'ln1butscmffl1. of 90",4,,c,f Usual, Customary; Rea:iO'nlililc"(UCR). Requw,; for lcimhursemcm. abo\tc lh� mte musl b,:; ncgotiatoo and · prior. lo ·the- sc.rvi� being. r<::flCk:rod. = Clnbiu billnn i�,ion .P r01;C1, Th_c- hMlth pt01,ider •11f �uhmil c.]1U1n$ using 1he approprllli.e f.:IAim form (cMS- 1500, 1450, UB92, or ADA orms) with a copy of lhe a� MedPAR to too address below'. t'Ieuc the oothori7..ation ':nwnber from the approved McdP on the form. Questions tt:garding stitus of cl-um!: or denials fot payment shc:mld abo be addro��i:d to the befow entity:: UB04, lllll:are AA ICE Health Service Corps VA Financi11\ Services Ceulct P,O. lior 14934:S Aw(in, TX 78714-934:5 800-4 79..-0.52.) 2020-ICLl-00006 1120 #520 P.034/057 05/25/2018 17:09 From: . ·--,..,__ ------, --...,,.- .C$OLA GE·NERAL :-HQSP!TA.'=""'L JNC. . 1;�.vr�: 1. /,osj iti�: 11�" -i,i ,16;.; ..i11;. )JO"-' · -iuii.:1:- .fl(f(fs{;_i_u,l_ .. --�w . .. . . .. -- -. . . .. 0-2 / 02 °"·"'· ii!ir1iie ·-. / 1!.SS 6 __'--'---fll6___ 1 )__ 1\b:111:41 �� Numw: -•-- T1M!f�ring F"!yoici,n .-----------.!:P=n=\l=f;:,:\·==!!!!'c.:M�n.:_______,__,.......________ I/hi/RI I I MO, MlCI) l.o�ci: Oowntu\\'I>; ', Atceptin� Pl>fS�il�.·: :.l!,;_:1�4, -···�,,.,_._' :nm� ---=•-i"P.� ---- -·--------- -�------ ·- - . ________ .. , ,.. ..,, ---· ----------------- ----------- D RM11'1i!'I� ----------------- (Z),,aa�,;lll.lrhiorill i�i(C)I 1-_______ CaC•. 0C/HJi8 2020-ICLl-00006 1121 #520 P.035/057 05/25/2018 17:10 From: ... : ...- ,.,1r.-l11.>�•e,Yl1 ";.n ,, ;""';L, t,.;Y p:-i11Jl · ·i,i,uw•:-,a.:...J.:;, · ·f.�il'W.,�J..:;�P"111,_...,,_ K� � �� -���� ,y.�. �-�-1rci� �lb� -�b,t J=m�;,i�-;: :�:i (��.1�J .,� ... 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'' ... ,, .. �.....,.��.,.,.11,o/..,jll .. : \,., _ � ..i: ll...S � I f'i'p;.r.,°""'�;,t ,u..,_,,.., in"'•�= X' _....,,.,,,..,is,,o,. _...,_ ..,, .,.,....if,o;J _t«,,,..,,_..,n,,·�,.),-.,•nd""•;.i.;..,11.,;,,;;i,,...,,..,1oh,,-,1�1, .. l<'!oc�lr.l!lofl:r.�'!)0"00ftl"""No"Jn, . . · � Qfl!IP. .; �tiiMI� I� ��� r.'ff" � • ,klrw:.�. ft·..,�:1 r .n.�ll'llt(..NQ 1h11 1 bi,"r-i.ntlll"'f�. ·•""�r'A"• ��- flU �'"C� ""'111·1.1•� ��et�◄.: "1-'t ft r "' '.U1� .,_--...,.r1,e1 J�!-': "'"�;«hii- l"ttlll h-ti�.,."nd W1e P"=i:l.i!I� n1,ls 61! i!Q( !:Cf.Cl 1n1n-:.,=:il'n!41 i.11i1•.-::·bLJC1·1 �•._.. I" r':"111: Nii� I �dlf MtJtl�"f.'� H..-11, t',"'1 ft..ot.. !il:iil �•�-r,w�-�. I M!"�ICIIC!1rtiM�. �-'"'!• ll'�•lo·•• _,,"'I ,,.,,,.,"'!""� �,i,,..,... .i-�l� � � -lo:I'. �....,, -=�� ,,.�&,.1,..,.. p,-. hJ )(6); (b)(l)(C) 2020-ICLl-00006 1122 #520 P.036/057 From: 05/25/2018 17;11 Pri�t date: 5/25/18 16:37 Pri nted by: l(b 6 � _)(_ _);_� #520 l'"'.037/057 � U M U L A T I V E REPORT selected Encounters Page CIBOLA GENERA� HOSPITAL 1016 E. ROOS E\TF.I,T AVE GRAN'l'S NM 81020 1 LABOAATOIU' �l20 years: O .358 ·3 .7t,O uTll/mt, ALL TSH VALUF.S REPRESENT 3RD GENERATION TSH SOURCE INFORMATION: 2020-ICLl-00006 1123 145 5.0 108 31 15 10.2 106 20 1.3 >30 116 67 37 l.C 8.2 S.5 4.7 2.4 115 393 308 0.056 1.13 0.9 2.0 UNITS - - - - - ........ mmol/L lWllOl/L rwnol/L mmol/L mmol/L mg/d.L mg/dL RATIO mq/dL mg/dL l'IIL/min/l.73m2 IU/L !11/L IU/L mg/dL G/dL g/dL mg/dL mg/dL JU/L U/L IU/L ng/mL �TIO mg/dL mmol/L From: 05/25/2018 17;11 Print d�te: S/25/18 16:37 Printed by, !ih\/R\· I R E P O R T C O M U L A T I V E Selected Encounter� HERNANDEZ JEFFRY OC-0166116 13,04 CMP Blood 13:54 PHOS Blood 13:54 �.AG Blood 13:04 AMY Blood 13,04 LIPASE Blood 13:04 CK Blood 13:04 TROP I Blood 15,16 CRP Elocd 13:04 LA Blood 17:46 TSH Blood Page LABORATORY 7):.,,.; (C'-'-)--'!M.D. u.;;;!(.,_,_ b)(6=-o);'-"(b:;,..)("-' CIBOLA GENERAL HOSPITAL 1016 E. ROOSEVELT AVE GRANI'S NM 8?02C NA.'lffi: MR# , 5/17/18 5/17/18 5/17/18 5/17/18 5/17/18 5/17/18 5/17/18 5/17/18 5/17/lS 5/17/lS #520 l'"'.038/057 DOB: 2/18/85 AGE: 33 SEX: M 2020-ICLl-00006 1124 PCP, IIDNE LOCAL 2 05/25/2018 17:12 From: Print d�te: 5/2 5/lB 16: 37 Printed by, �kb�\�/6�\�:-� #520 P.039/057 C U M U L A T I V E REPORT selected Encounters Page CIBOLA GENERAL HOSPITAL LAI!ORATORY !(b)(6); (b)(7)(C) 1016 E. ROOSEVELT AVE NM 8702 0 GR.11,NTS NAME: HERNANDEZ JEFFRY MR# : 000166116 DOB: 2/18/85 SEX: M 1/CP: NONE LOCAL COACUL!\TION COLLECT 2018 YR DT REFERENCE LOW· HIGH 05/17 13, 04 TM 15.7 PT 9.8 I{ 1. 3 H JlilR 30.3 APTT D DIMER 449 REPORTED DT '™ ti 05/17/18 14:31 Primary and secondary prevention of venous thrombosis Range INR Target 2 - 3 Prevention of recurrent venous throll\bosis Prevention of arterial 3.0 thromboemboliGm including patients with mechanical heart valves 2.5 - 3.5 J.0 *•• New Prothrombin Time reference ranqe effective 2·1·18 ••� ** Cibola General Hospital Laboratory** Heparin Therapeutic range for APTT is 48-74 seconds. The 11\MU!�cturer of the D-Dimer aseay has approve� a cut·off of 230 ng/ml. The rnanutacturer states that with this cut -off the Negat.ive Pn,diot i ve Value of the test is 100% with specificity between 36%-Jg�. D·Dimer re£ults are reported in ng/mL. The.sc units correspond to ng/mL of D-Dime= �nits (D·DU). SOURCE IN�ORMATIOO: 5/17/18 lJ,04 PT 5/17/18 D,54 AP'M' Blood 5/17/18 13,54 D DIMER Blood Blood 2020-ICLl-00006 1125 14.S UNITS seconds INR o.s 25 1.2 40 Seconds 0 231) ng/mL 1/l.D. From: 05/25/2018 17:12 Print date, 5/25/18 16,37 Printed by: l"-'bf a.:).:.a(6:.a):'-_ _. C U M U L A T I V E R EPOR T Selected Encounters Page CIBOLA GENERAL HOSPITAL 1016 E. RCOSEVELT AVE GRANI'S NM 87020 NAME: HERNANDEZ JEFFRY MR# : 000166116 #520 P.040/057 LABORATORY kbl(6l (bl(?l(Cl DOB, 2/18/85 AGE: 33 SEX: M PCP: NONE LOCAL HEMATOLOGY COLLECT YR DT 2-ns 05/17 13:04 ™ 5 6 WBC 3.16 8.6 25.3 80.1 RBC HGB }IC'f MCV MCH MCHC RDW REFERENCE LOW - HIGH L L L 27 .2 L 33.9 LY'!; 69 L 10,7 H 42.9 33.4 MO% 22.9 EOI\; 0.2 MPV NE% 11.6 150 7.4 9.6 6.00 16,ll NE# 2,4 Z.Y# 1. 9 MOit 1.3 !! 0.0 0.0 YES 42 DIFF NEUT 1.8 1.0 0.2 0.0 0.0 4� s BM'D LYMP 0 35 MONO.. EOS FLT EST 18 H 0 DECREASE REPORTED DT TM 05/17/18 13,25 SOURCE lN�ORJ-'.ATION, S/17/18 13:04 C.BC COIWJENTS: 5/17/18 13:25 CBC Blood Platelet evaluation agrees with automated count Few �mudge cells present 2020-ICLl-00006 1126 10/3 UL 10"6/uL G/dL 48 98 33.3 34. ij 13,7 450 10.4 0.6 BAiii MAN 33.0 14. 3 H PLTA EOlt BA# 3.6 4.64 12.0 35 81 27.6 L UNITS 7.0 3.4 0.8 0.3 0.1 76 5 16 2 47 0 �-0 10 fL .. pq G/dL .. 10"3/UL fL .... ...... 10"3/uL 10"3/uL 10"3/uL 10· _1/uL 10"3/UL .... .... ital 5/17/2018 166116 12018-05-17 15:37:01 not on flle 2018-05·17 15:40:05 2020-ICLl-00006 1136 1 #520 P.051/057 05/25/2018 17:16 From: User: Facility: CIBOLA GENERAL HOSPITAL All Orders History 5/25/17 thru 5/25/18 l(b)(6); 1 1 5/25/18 16:39:11 Page: Date: Time: Encounter: HERNANDEZ JEFFRY 4499030 Date of Birth: 2/18/1985 Order Type: Sequenced by: - ,._ ,. ,. ., .. .., ... - - - - - All Entered Date - - - -- - - - - - - - -- - - - - � � - - - - - - - - - .. - .. .. • - - - - - - - - - - -- - - - - - 5/17/18 17:46 Ancillary Order#: 2800 Desc: TSH 3RD GENERATION Occurrences: 1 Frequency: ONCE/DAY Priorlty: Stat Source: Blood Ancillary Instructions: Yellow SST or Green Top Tube Order Origin: eOrder------� Ordering Physician: �(b_..,,)(6""""),"""(b.....)(_?l_(c_i___,_.____,, Electronically Signed by: (b)(6);(b)(7)(Cl 5/17/18 17:46 I Entered by: !1h\1R\· lh\17\IC:\ 5/17/18 17:46 Ancillary Order#: 2700 Desc: HIV CONFIRMATION Occurrences: 1 Frequency: ONCE/DAY Prior1ty: Routine Ancillary Instructions: 0#91431 3ML SERUM REFRIGERATED Order Origin: Writte,..wn�-----� Ordering Physician: (b)(6); (b)(?)(C) �- • - - -- - - -- � - r - - - - - - - - ... .,. ,.....,_.,. - - Start: 5/17/18 17:46 Start: 5/17/18 17:46 Start: 5/17/18 17:16 Entered by: (b)(6); (b)(?)(C) 5/17/18 17:16 Ancillary Order#: 2600 Desc: CONFIRM GRP A STREP Frequency: ONCE/DAY Occurrences: 1 Priority: Routine Source: THROA Ancillary Instructions: Use for negative rapid strep. Order Origin: Written------� Ordering Phys i Ci an: !(b)/6): (bl(7)(Cl Entered by: l(b)(6): (b)(7)(Cl I 5/17/18 16:59 Ancillary Order#: 2500 Desc: RAPID STREP GROUP A Occurrences: 1 Frequency: ONCE/DAY Priority: Stat Order Origin: eOrder______� : l< 7l=age: Date: Time: CIBOLA GENERAL HOSPITAL All Orders History 5/25/17 thru 5/25/18 1 4 5/25/18 16:39:11 Encounter: 4499030 HERN/1.ttOEZ JEFFRY Date of Birth: 2/18/1985 Order Type: Sequenced by: All Entered Date ______ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ., _ ___ ___ _ _ .., _ ,_ _ _____ .., _ _ _ _ _ _______ __ .. _ _ ,.. .. _ _ __ .., _ _ _ _ .. . .. .... - - -------- - .. •--- - - .. -- --- - 5/17/18 13:55 Ancillary Order#: 1200 Desc: EKG Priority: Stat Frequency; ONCE/DAY Order Origin: eOrder Order1ng Phys1cian: �b�K���:(b�K�7lrn��i--7 Electronically Signe b : b 6),(b)(7)(Cl Entered by: (b)(6);(b)(7)(C) Occurrences: 1 5/17/18 13:04 Ancillary Order#: 1000 Oesc: TROPON!N-I Frequency: ONCE/DAY Occurrences: 1 Priority: Stat Source: Blood Ancillary Instructions: Green top or Yellow SST tube Order Origin: eOrder:.,,..,...,=-;; ;:;,"' 7 Ordering Physician: b)(6);��l(7)(C�)-(6);(bl J( l y: 5/17/18 13:04 Electronically Sign Entered by: (b)(6); (b)(7)(C) 5/17/18 13:04 Ancillary Order#: 900 Desc: PROTHROMBTN TIME Frequency: ONCE/DAY Occurrences: l Priority: Stat Source: Blood Ancillary Instructions: Slue top Citrate tube Order Origin: eOrder = Ordering Physician: �b...,6 ).--::-b-:-::;:"::;:c-:---7 S/17/18 13:04 Electronically Signe by: (b)(6);(b)(7)(C) Start: 5/17/18 13:06 Start: 5/17/18 13:04 Start: 5/17/18 13:04 Start: 5/17/18 13:04 Start: 5/17/18 13:04 (b){6); (b)(7)(C) 5/17/18 13:04 Ancillary Order#: 800 Desc: LI PASE Frequency: ONCE/DAY Priority: Stat Source: Blood Anc1llary Instructions: Green Top Tube Order Ortgin: eOrder .,..., "' Ordering Physician: =�)(= 6)�;��l(n7) (C�)--1 Electronically Signed : b(6J;(b)(7)(Cl Entered by: 5/17/18 13:54 5/17/18 13:55 5/17/18 13:06 Ancillary OrderU: 1100 Desc: SPECIMEN DELIVERED Occurrences: 1 Priority: Routine Frequency: ONCE/DAY Order Origin: Wrltten ....,.""""..,.=""',:-:-7 Ordering Physician: ��-l�); (b)(7) C )-- Pn1 ebotomi st PHLEB Entered by: (b)(6);(b)(7)(C) Entered by: Start: b)(6); (b)(7)(C) Occurrences: 1 5/17/18 13:04 5/17/18 13:04 Ancillary Order#: 700 Desc: LACTIC ACID Frequency: ONCE/DAY Occurrences: 1 Priority: Stat Source: Blood Ancillary Instructions: DRAW IN GREY TOP TUBE 2020-ICU-00006 1140 05/25/2 018 17:18 #520 r.oss1os7 From: User: Fae il i ty: CIBOLA GENERAL HOSPITAL All Orders History 5/25/17 thru 5/25/18 Page: Date: Time: 5 5/25/18 16:39:11 Encounter: 4499030 HERNANDEZ JEFFRY Date of Birth: 2/18/1985 Order Type: All Sequenced by: Entered Date _________________________________ ,.. _______ ,.. ______ ,.. ____ _____ ___________ ........ ___ .., _____________ .., _____ _ Order Origin: eOrder """";:;,;-;-;."" ,(b)(7XC)-Ordering Physician: ·..,,..,...,x6=)--= 5/17/18 13:04 Electronically Signed b : b)(6);(b)(7)(Cl Entered by: (b)(6);(b)(7)(C) .,. ,.. ,.. 7 5/17/18 13:04 Ancillary Order#: 600 Discontinued Start: 5/17/18 13:04 Desc: URINE DRUG SCREEN Occurrences: 1 Priority: Stat Frequency: ONCE/DAY 0/C Reason: HO SPECIMEN 0/C' d by: l{!>X6)· (b)(7 XCl } LAB Di rector 5/21/18 10:15 Order Origin: eOrder ___,��--, _ XC ) l Ordering Phystcian: @X6),(b)(7 Electronically S1gned by: b 6; b 7 c 5/21/18 10:15 Entered by : )(6); (b)(7)(C) 5/17/18 13:04 Ancillary Order#: 500 Desc: COMP METAS PANEL Frequency: ONCE/OAY Priority: Stat Source: Blood Ancillary Instructions: Green Top tube Order Origin: eOrder�.,.,.....,,...,.,,,=--7 I Ordering Physician: kf>X6);(b)(7XC) Electronically Signeab : X6);(bX7 )(C) Entered by: b)(6);(b)(7)(C) Occurrences: 1 5/17/18 13:04 Start: 5/17/18 13:04 Start: 5/17/18 13:04 Start: 5/17/18 13:04 5/17/18 13:04 5/17/18 13:04 Ancillary Order#: 400 Desc: CK TOTAL Frequency: ONCE/DAY Occurrences: 1 Priority: Stat Source: Blood Ancillary Instructions: Green top or Yellow SST tube Order Origin: eOrder --="""" ;;::-.Ordering Physician: -l(b-.X= � C) ---il 6 )", (b)(7X · <6Ub\m MedPAR is administratively approved for air EMS PHI AIR MEDICAL transport on 05/17/2018. Authorized payments for health care services will be reimbursed in accordance with Title 18, Part III, Chapter 301, Section 4006 of the U.S. Code and shall not exceed Medicare reimbursement rates unless explicitly authorized. Payment for authorized services is subject to custody verification. Claims must be filed within a year of the date of service. l(b)(6) ;(b)(7)(C) Patient ID#: 206418141 Patient Border Patrol # : FBI Patient FIN# : 17851616 Patient Last Name: HERNANDEZ Patient First Name: JEFFRY Patient Middle Name : Patient Suffix : Patient Date Of Birth: 02/18/1985 Patient Sex: M Patient Nationality: HONDU Patient HSI Number : Provider ID : Provider Name : PHI Air Medical Air Evac Provider Specialty : Ambulance - Air Provider Facil ity Type : Provider Provider Type : Provider Address1 : 2800 N 44th St. Provider Address2: #800 Provider City : Phoenix Provider State : AZ Provider Zip : 85008 Provider Phone : 602-244-9327 https://rnedpar2 .ehr-icehealth.org/HorneN iewRequestAuthorization/ I 04336 2020-ICLl-00006 1149 5/30/2018 MedPAR Authorization Form Page 3 of3 https://medpar2.ehr-icehealth.org/HomeNiewRequestAuthorization/104336 2020-ICLl-00006 1150 5/30/2018 Page 1 of 2 MedPAR Authorization Form Treatment, Authorization & Consultation Form ICE Health Service Corps SEND PAPER CLAIMS TO: ICE Health Service Corps VA Financial Services Center PO Box 149345 Austin, TX 78714-9345 For EDI claim submission information and claim inquiries, please contact 1.800.479.0523 Claims must be submitted within one year from date of health service, For proper provider claim submission information, please visit: https://www.ice.gov/ihs­ ma nagec:1-ca re A separate treatment authorization request will be required for services beyond and outside the scope of the original authorization. Services rendered may not be paid without an approved authorization, All payment for services is subject to detainees™ eligibility and custody. Unless otherwise specified, payment for IHSC authorized health services is made in accordance with US Code Title 18, Part 3, Chapter 301, Sec. 4006. All claims are subject to retrospective review. For further information regarding IHSC, please visit our website: https://www.ice.gov/ice-health-service­ corps Please ensure all claims include the Patient Identification Information and the Authorization code. IMPRINT OF DETAINEE ID PLATE, COMPUTER LABEL OR COMPLETE BELOW: PT Name: JEFFRY HERNANDEZ DOB: 02/18/1985 Nationality: HONDU Alias: ID#: 206418141 Facility: CIBOLA COUNTY CORRECTIONAL CENTER AUTHORIZED ACTION: Status: Approved Authorizer: ,...(! b-)(6-);-(b-)(-7)-(C-) ----. Auth Code: 2018053000476 Appointment Date: 05/17/2018 Cer1:ification Statement: l(b)(6); (b)(?)(C) See MedPAR Authorization Information below for authorization details Diagnosis: R65.21 - Severe sepsis with septic shock Request and Reason: Septic Shock Inpatient Services https ://medpar2.ehr-icehealth.org/HomeN iewRequestA uthorization/ 104 349 2020-ICLl-00006 1151 5/30/2018 Page 2 of2 MedPAR Authorization Form Notes: Inpatient hospital services for septic shock from 5/17/2018 to 5/25/2018 MedPAR Submitter Information Date: 05/30/2018 14:51:38 Name: b 6 ; b 1 c Phone: (915) 856-(b)( 6); e-Mail: !(bl(6); (bl(7l(Cl I Provider: Lovelace Medical Center - Downtown 601 Dr Martin Luther King Jr Ave NE Albuquerque, NM87102 MedPAR Authorization Information t(bl(6l:(bl(7l(Cl KJ5/30/2018 15:54:42 > Approved for access to medical care to include inpatient hospitalization at LOVELACE MEDICAL CENTER beginning on 05/17/2018 with discharge date of 05/25/2018. Authorized payments for health care services will be reimbursed in accordance with Title 18, Part III, Chapter 301, Section 4006 of the U.S. Code and shall not exceed Medicare reimbursement rates unless explicitly authorized. Payment for authorized services is subject to custody verification. Claims must be filed within a year of the date of service. Patient ID # : 206418141 Patient Border Patrol # : FBI Patient FIN # : 17851616 Patient Last Name: HERNANDEZ Patient First Name : JEFFRY Patient Middle Name : Patient Suffix : Patient Date Of Birth : 02/18/1985 Patient Sex : M Patient Nationality : HONDU Patient HSI Number: Provider ID: Provider Name : Lovelace Medical Center - Downtown Provider Specialty : Hospitalization, Inpatient Provider Facility Type: Inpatient Hospital Provider Provider Type : Provider Address! : 601 Dr Martin Luther King Jr Ave NE Provider Address2 : Provider City : Albuquerque Provider State : NM Provider Zip : 87102 Provider Phone : 505-727-8000 https://medpar2.ehr-icehealth.org/HomeNiewRequestAuthorization/104349 2020-ICLl-00006 1152 5/30/2018 05/30/2018 WED 101 29 FAX 6023813767 PFS Fa:< FAX ( AfR ", MBDIGAL � I ,M- • ...!'-t!.�ND TO: FROM: DATE: v� □ �001/009 TNl (Al!--,.- I ice Health Service Corps I I 05Iao,201 a PHI A(r Medical 2800 N 441� Street Suite 600 Phoenix, AZ 85008 Phone: 602�224-3500 Fax: 602-381~3767 Toll Free:1-800-421-6111 jFAX#: j(b)(6); (b)(7)(C) urgent - Reply ASAP ,� I aes-113-12os □ 0For Approval I 'f Doriginal To Follow Please Confirm Receipt Of Fax 0Pleasa Comment ATTENTION; �b)(6); (b)(7)(C) 1 f.��� � A tt,frice of PHI A'ft Medlr:al !PAGE(S) INCLUDING COVER: 0ForRevlew [}YI • No Response Necessary /( OE ACCOUNT: 275634 PLEASE SEECLINICALS FOR: JEFFRY HERNANDEZ DOB: 02/18/1985 DOS: 05/17/2018 PLEASE CALL ME JF YOU HA VE ANY QUESTIONS !(b)(6); (b)(7)(C) I 800-421-6 l l 1 EXT l(b)(B); I (b)(6); (b)(7)(C) Patient Financial Services Department The il'lformation contained in rhis facsimile message Is conj]d,m!llrl infonnar/011 lmen.ded i:infyfor the ffSe Qf fhe individual or en/if,) n�mecl above, lf1he reader 0/11!/s messt1ge is not the intended recipie'II, r r the employee or agent re:1porrsibfe 10 deliver It to the tmerrded reciµienl, •yau are he1·eby l't()lified thof any dim:mirmtion. distributiori or 1',,pying of r}ns commu11ica1ion Is strictly prohibited Ifyou have rece/�ed ihis CPtr1mwnication in error, please fmmsdtarely HOl{jy us by tele),ho>is and l'etum the orig/nQ/ message lo 11s al /he ab,ne arldre:;:; via the U.S. Postal S!lrvlct. rhankyo1,. /11 case ofanj problems dilr{ng 1rans111i.rsion, please conracl the sender al the phone number above, 1 ( 2020-ICLl-00006 1153 05/30/2018 WED 101 30 FAX 6023813767 PFS Fa:< �002/009 Transport Medical Record ' ' Patient Info Transport Information Transport Info 2018-05-17 Record Number: 64-18-3311 OA Date of Service Patient Name Mi&sion Type tnterfaclllty Call - Medical Possible Injury Present? No Hernandez, Jeffry Patient AKA Hernandez, Jeffry Patient �orm Adult Name Patient Gander Male Patient Height 5.0ft Patient Weight Ideal Body Weight PJi)«tnt DOB Emergency Rotor• lnterfacilily Call Type Base Grants 40.91 kg Controlllng MO 52.0 kg Sanding Hosp. MR #: 166116 Rec. Hosp. MR#: IPM 33 Years Patient Age PHI Mer:I 5-3 • N356P Unit: 1985-02-18 UNK c-iHi :U�ffl��'.1:-�•'. I b)(6); (b)(7)(C) ,,,. n�:m�;�r;!�]"; l:·:.i'.�Q�_?:.·:;< •.,� �-, ;·,��\\ RN Sending and Receiving Cibola General Hosp-Grants Sane.ling LZ Receiving LZ Sending Faclllty Cibola General Hosp-Grants Receiving Faclllty Sending MD Bearn5ley Receiving MD Sending Unit Type of Destination Emergency Oepartrnent Receiving Unit Lz Heart Hospital of New l.1exico Lovelace Medical Clr Downtown Mazer Hospital-Emergency Department ICU Reason for Transport (medical necessity determination) Sending Level of care required which Is not available at patient's location Specially Services Requiroo: ICU - Adult Receiving Transport by �mother method to the appropriate fa.<::ility would take too long Transport Transport Details I P;fr((ent Consent EMS local protocol utlllzed Level of Care PTA/Place of Exam Outcome of PTA Aid Written N/A Emergency Dept I ER bedside lrnproved Page 1 of 8 2020-ICLl-00006 1154 05/30/2018 WED 101 30 FAX 6023813767 PFS Fa:< �003/009 Impressions . Fever, unspecified 1 Time of Call Dispatch Times Tlfll.8 Dispatch lfme Enroute 05/17 20:07 MDT 05/17 20:10 MDT 05/17 20:59 MDT Arrive Faclllty 05/17 22:04 MDT Dep&rt Faclllty Depart with Patient Accepting Unit Slgnover 05/17 21:38 MDT • / Clinical Times Rendezvous 05/17 20:15 MDT Arrive Scene Depart Scene Time Oneet ' 05/16 08:00 MDT 05/17 21 :07 MDT 05/17 21:30 MDT 05/17 22: 15 MDT 05/17 22:26 MDT 05/17 22:52 MDT Incident Information Not Required Transport Information I Altitude Transport Loading Transport Device NVG Utlllzed Transport Position 8300 Cabin Pressure Signed Over to Al rcreft 5tretcher Condition at Slgnover No HO8 Elevetlito 30 degreei /h\/R\ /h\/7\/C:\ Improved I r · Safety briefing given bYkbl/6\ /b\/7\/C\ [PM] to Patient. Natlfled of Privacy Practices given. Eye protection supplied to petient. Ear prot1;1c1ion supp II ed lo patient. Safaty straps used to secure f)ati1;1nt for tra n5port. Str!ittcher and/or lsolette secure cl for Ira nsporl. Continue PTA tr¥}911mt. Patient Medical History . Chief Complalnt ( I Complaints cough, sore throat, headache, dx sepsis. Duration: 2 Days Symptoms Primary Symptom j 111 ness, unspecified History of Present Illness/Injury PHI Med 53 was requested by fbl/6)'. 2 Years); Smiles; ori8nted to sounds; follow& objects: lntfilracts). M ..6 - (Obeys commands (>2Years); Appropriate fl!spon9e lo stimulatton). Perto,med By: �kb=)(6�);____, [RN) :: F1owerad by Golden H!"lut ® I 2020-ICLl-00006 1158 Page 5 ofB ,. 05/30/2018 WED 101 32 FAX 6023813767 PFS Fa:< �007/009 Scores (cont.) I 05117 21:38 GCS 15 05/17 22:26 MDT GCS 15 MDT E-"4 - (Opens Ey� spontaneously), V-"5 - (Oriented (>2 Years): Smiles: oriented to sounds; follows objects; interacts), M=6 - {Obeys commands (>2Years); Appropriate response to stlmulatlon). Performed Byj(b)(6); (b)(7)(C) I [RN] 4. (Op$r'I$ Eye$ aponraneously), V•6- (Oriented (>2 Yea�rnil"; oriented to sounds; follows objects; Interacts), M=6 - (Obeys commands (>2Yeare); Appropriate response to stimulation), Performed BYl(b)(6); (b)(7)(C) I e .. [RN] " ,.. p Vital S,gns and Associated Monitoring I Oon11o■nllml Ps9e B of 8 2020-ICLl-00006 1159 05/30/2018 WED 101 33 FAX 6023813767 PFS Fa:< Medications ✓ May 17, 2018 21 :30:07 MDT I II �008/009 May 17, 2018 21 :a�·:o7 MDT Medication: 100 ml/hr of Lactated Ringer's Solution given es IV □ rip Transport lime by!/h)(R\· /h\/7\/C:\ I [PMI via lnlralJenous (IV). Authorization: Protocol (Standing Order). Complications: None. Response was: lmprov1:1d. Notes; carrier for noreplnephrine. ov ![PM] via MedlcaUon: 6 rncg/min of Noreplnephrlne gtven as IV Drip Transport Time !/b\/6\ lntra..-enous {IV). Authorization: Protocol (Standing Order). Complications: None. Response was: Improved, Notes: Concentration 4mg/250 ml NS. Rate 16.75 rnVhr for hypertension sip fluid resusitation. Protocols EventLog 05/17 21 :30 MDT 05/17 22:26 MDT Medical Decision Making Sp02 98-100'¼ on room air. Pt transported without 02. Other; Pl transp(lrt$d lo receiving unit end moved to ICU bed with no Issues. IV remains in..,,t&eti ,and Infusing with no problems . Course!Signovcr/Followup .r !Velual'llee: none, Patient Transport Chronology ·.?.. 05/16 08:00 MDT 05/17 21:07 MDT 05/17 21:08 MDT 05/17 21:18 MDT 05/1711:28 MDT 05/17 21:30 MDT 05/17 21 :30 MDT 05/17 21 :30 MDT 05/17 21:31 MDT .I 21:38 MDT 21:38 MOT 05/17 21 :48 MDT 05/11'21 :58 MDT Powered by Golden Hour ® Time Onset Rendezvous GCS Score: 15 BP 60/ 54 PULSE: 101 RR 13 SP02 96% AMC at bedside. Plan of care dlscui::sed. Con-':lent signed. BP 81/ 60 PULSE 93 RR 18 SPO.2 98% Pt lraneferred lo aircraft stretcher with no problems. rv•e remain intact. Event Log: Medical Decision Making. Sp02 98-100% on room air. Pt tr::iin5'ported without 02 .. Depart with Patient Lactated Ringer's SoluUon 100 ml/hr carrier for noreplnephrine Noreplnephrine 5 mcg/min Concentretion 4mg/250 ml NS. Rate 18.75 ml/hr for hyperten9lon sip fluid resusitaliori GCS Score: 15 6P 105/ 70 PULSE 77 RR 12 SPO2100% Lifting from hellped. Pt with no problems at this time. BP 101 / 76 PULS� 79 RR 20 $P02 97% Pt tolerated take off and �ccent with no problems. IV Infusing with no i$-':lues. Radio report called with no new ordars at this time. ap 10e/ 69 PULSE 78 RR 20 Continue In flight wllh no problems, $P0295% Page 7 of 8 IConlldorl.lol 2020-ICLl-00006 1160 05/30/2018 WED 101 33 FAX 6023813767 PFS FalC i;EI009/009 Patient Transport Chronology (cont.) BP 99/ 69 PULSE 79 RR 23 SPO2 9Ei% Pl being transported from AC to recaiving hospital via ambulance. Accepting Unit 05/17 22;08 MDT 05/17 22:15 MDT SPO2 99% BP 103/ 79 PULSE 19 RR 15 P1 awake with no change In assessment. Evant Log: Other:. Pt transported to receiving unit and moved to ICU �d with no issua9. IV remains In plaC$ and inf1,1sing with no problems .. 05/17 22:26 MDT 05/17 22:26 MDT GCS $cote: 15 Slgnover e' Was the patient EMS Agency: ( Intercept Documentation brought to the aircraft by Ground Ambulance Was the patient taken from the aircraft by Ground Ambulance E:MS Agenc:y: Superior Ambulance . I No I nte rce pt L.o<:: a tion : Yes Intercept Location: He.:irt Ho�it,al lielll'Je.d Signatures l(b)(6); l[RN] as (Dig Ital Signature] 05/18/18 07:50 fbl(6l: (bl(7l(Cl ![RN] Date & Time !(b)(6); (b)(7)(C)� [PM] as [Dlgltal Signature) 05/18118 07:49 l(b)(6); (b)(7)(C) I [PM] Date & Time ( I Powered by Golden Hour® L..:lc.,,.=111=""'=::_.1" _____________________, 2020-ICLl-00006 1161 Peg1;18 o/8 Declaration of Next-of-Kin l I, l(b)(6); (b)(7)(C) an adult of sound mind and body, freely and do hereby make oath and state under penalty of perjury of the laws of the United States of America pursuant to 28 U.S.C. § 1746 that 1. I am the sister and next-of-kind of Roy Alexander Hernandez Rodriguez, born 2/18/1985, al o known a Jeffry Hernandez. L of 2. I am represented by attomey!(b)(6); (b)(7)(C) I and his law firm, The Law Office o�(b)(6); (b)(7)(C) a hville, Tennessee PO Bo 90568 ashvill.e 37209. By thi Declaration, I expressly authorize Mr. l(b)(6); I and his agents to communicate and receive information on my behalf 3. I hereby formally request that j(b)(6); (b)(7)(C) 4. !perform an autopsy on my sister. I hereby request access to and copies of and, on behalf of my sister as her legal representative and the putative heir to and administrator of her estate, authorize the relea e in full of any and all records and infonnation of or regarding my sister to The Law Office of l(b)(6);(b)(7)(C) I or to l· NC .... · HO N N 1 fil3 G - NC LO IL----,---------r-----=f--�0:!:6/�:::, ::::84_!.!::,:,�O�U�+-8�e c __l·-M� I I I I certify c:ompliance with 11/ ICE Detention and Transfer Standards and ICE Air Boarding Requif(!ments for thf:s ICE Air/Charter movement. File No. Niltfonality �g��� S1�lus (1) :� Criminal History Sex �� � t· ·-co- �::::�::�. . �� _____ --------- Name and Tme: Off,cc: Contact Numbe�s): ( 1). Show whelher lran�lcr or removal, Fer transfers show whelher NTA or Final Order (F/0) {2). Show medical contlitions. high risk, Right ri:;k, epileptic, insane. e:c.. Use a separale line for each person transferred. This form is lo b9 e�ecutoo in sufficient number a! copies to allow receiving officer lo reteln one copy of his personal expense voucher and two addilicnal copl.s for station ol final �elivery. R8Celved the al>Ove lis1ed3per.; (b){6); (b)(7){C) Signature: T i Ue PI ace and Date: ________j-------------=::,>-:-t,;£/ ---------------------------:.4�·Di-�,.___ ___:.r- _t._-�f/F---------- 2020-lCLl-00006 1172 ___..5 ,:._ . IMMIGRATION AND CUSTOMS ENFORCEMENT EL PASO SERVICE PROCESING CENTER ICE G-391 FORM /9S-bf0 STARTING MILEAGE: EN DI NG MILEAGE: ___,_/__,9"-' - §"' '2_"'-�-=-----­ ,.___,.. TOTAL TIME FOR TRJP: h 5-'0 TOTAL MILEAGE FOR TRIP: _........,...3 .,,,,-_____ ORIGIN: �y, TRANSPORTATION. OP ERA TIO NAL D ESTl NATI ON S �c NAME/PLACE ADDRESS ½>t CITY AND STATE ti.��ful ENDING MILEAGE DESTINATION 1: "'MOVEMENT TYPE \\<\ -.., t_.�o J ;5,JJ\ d-� . J...,. ➔ -���:::.--=:J NAME/PLACE ADDRESS CllYAND STATE q_'-- l'i-�Cc.! STARTING MILEAGE o e,._ � ARRIVAL TIME 0.,J -.;A. q_ - -nc DEPARTURE TIME \, J TOTA_L DETAINEES *MOVEMENT TYPE t7l{� NAME/PLACE AEAWPil TIME ADDRESS DEPARTURE TIME \__ ewo CITY AND STATE DESTINATION 3: ,til:w� STARTING MILEAGE ENDING MILEAGE "'MOVEMENT TYPE NAME/PLACE ARRIVAL TIME ADDRESS CITY AND STATE STARTING MILEAGE L,/ ENDING MILEAGE TOTAL DETAINEES / *MOVEMENT TYPE PRINT AND SIGN PRE-TRIF PRINT AND SIGN POST-TR APPROVEDSODO: _ PRINT NAME:_ DATE: END TIME / (b)(6); (b)(7)(C) ,-,.,..-,-c, r:;;:t ;;: �<;,�'=,] TOTAL DETAINEES SUPERVISOR: I ·3,Cf-::::, Jc:eiV \�;I.:,� ENDING MILEAGE DESTINATION 2: -\� -LW id/Jr-e- STARTING MILEAGE TOTAL DETAINEES -- G START TIME ..#=if! (b)(6); (b)(7)(C) fii -· I CL , CJ DRIVER SIGNATURE:_ PRINT NAME:� � b)(6); (b)(7)(C) o;_.:; I l 5 I 2-u/ ti DATE: CO-DRIVER SIG/I (b)(6); (b)(7)(C) PRINT NAME: DATE: 2020-ICLl-00006 1173 ;"')-{ -:;-·( ! DESTINATION 4: ARRIVAL TIME NAME/PLACE DEPJl:RTURE TIME ADDRESS CITY AND STATE - STARTING MILEAGE ENDING MILEAGE . TOTAL DETAINEES DESTINATION 5: *MOVE MENTTYPE NAME/PLACE ADDRESS / CITY AND STATE STARTING MILEAGE / / ARRIVAL TIME DEPARTURE 11 ME ENDING MILEAGE TOTAL DETAINEES DESTINATION 6: NAME/PLACE ADDRESS CITY AND STATE 'MOVE� I __/ ARRIVAL TIME DEPARTURE TIME STARTING MILEAGE ENDING MILEAGE TOTAL DETAINEES • MOVEMENT TY PE TOTAL# OF DETAINEES CIRCLED AND ANY ADDITIONAL NOTES REGARDING TYPE OF MOVEMENT; IE. HOW LONG YOU HAD TO WAIT BECAUSE OF CHANGE OF SHIFT, NO PAPERWORK, COUNT TIME, DELAYS ETC. "'MOVEMENT TYPE: JAIL PICKUP, RELEASE, ATD, GREYHOUND, NGO, LEGAL, LAND REMOVAL, ICE AIR TRANSFER, AIRPORT, AMBULATORY, MED!CAL, OTHER 2020-1 C Ll-00006 117 4 Form 1-216 Maniftst No, __ 37_2_20_1_9 ... (p_ag,._e_1_o_r�1 )__ U.S. DEPARTMENT OF HOMELAND SECURITY IMMIGRATION & CUSTOMS ENFORCEMENT (Rev .04/26/11,) FROM: SAN LUIS REGIONAL □ ET CENTE Origin FO: -SAN DIEG01 CA FIie No. I (b)(6); (b)(7)(C) , Name cf Person '"".,.. VIA(1) ____ VIA(2) ____ I Nationality DOB HONDU . ·-·HONDU IJEFFRY b)(6); (b){7)(C) t n?/1RIR• HONDU HONDU MEXlC BG 8G BG 8,G BG I certify com Name and TiUe HONDV HONDV -· BG NC NC N NC N N N llle9el Entrv NC M M NC NC - M . .MM Dffice, (2) • Sh:>1'1 medical conditions, n:gh risk, fiight risk, epileptic. insane, el.c. Use a s�parate line for each pcrsoo tran·srerred. This form is to be el(eCUled in sOfficient 111Jm'ber of copies \1> a110\'1 receiving oft,cer In retain one copy of his personal expense vo�cher anct two add1l1onal copies for stalion of frr.al deliV!!IY. N NC NC NC NC M NC LO .......- LO LO Slgn�!ure: TIUc; ?lace and Dale: 2020-ICLl-00006 1175 �---- ·1----�-.. ·�-- LO LO LO ·- .. I _; Received the above listed persons Comments (2) •· l.0 for this ICE AJr/CJ'larler movement Contact Numbcr(s): Subject 1D LO ... 17851616 LO I 36134278! LO ,.... �......b)(6), (b){7)(C); (b)(7)(E) l.O LO �..----.. LO N N ., I LO N N Flns# b)(6); (b)(7){C); (b)(7)(E) LO LO N NC _,_..,. Other: ______________ LO LO 05/15/18 ---------- MODE: _____________ Class. Level N N NC M. N N NC M M Gang Membershio N N N N NC �nsfer Standards and ICE Air Boarding Requirements · {1) - Show whether transfer or removal. For transfers siJD•,v 1wielher NTA or Anal Order (F/0) , .. ... NC M M HONDU NC M M BG ·.... _BG GUATE NC M GUATE MEXIC HONDU BG BG Criminal Hlstmy M BG HONOU -" '/ ,..JL M M M HONDU .. sex 8G BG BG BG BG ---GUATE - Sta\LJS (1) 8G HONDU , TO: CIBOLA COUNTY CORRECTIONAL CEr Dest. FO: ALBUQUERQUE, NM 8G BG . ---�g�g� HONOU , AWO'll8141J.!:i!=RN!!NDEZ Transfer Date: RECORD OF PERSONS TRANSFERRED / I ,,.r/l ·7� (� tv Form 1-216 M,11ifesf No. __3_722-'---0--'-19_.(.._aP ..,_g_a _t """of_1,_) _ US. DEPARTMENT OF HOMELAND SECURrrY IMMIGRATION & CUSTOMS ENFORCEMENT {Re�.04/26/11) FROM: SAN LUIS REGIONAL OET CENH Origin FO: SAN DIEGO. CA FIie No, I , (b)(6), (b)(7)(C) riame or PE rsi,n FIRSl I.AST I '208418ti1 ll-ll"RNANOEZ b)(6); (b)(7)(C) TJEFFRY ·- I I VIA(1)_�-VIA(:Z) ____ DOB Nallon,;.llly HONOU TO: CIBOLA COUNTY CORRECTIONAL CE? Oest. FO: ALBUQU£RQUE, NM 51.'IIUS (1) 8 -·7=roIBu f-- HotT□u-" .._, __ SG HONOU 80 ·-,_ HO}'IOU�- -··-iG--GUATE -· -··HONOU BG - S Q-HON� --·"aG ___ I 02/18/85 - --«owffiJ· HONDD 80 ,-. 8G -·7rc"---i:iexic-- ..----8G ___ -GUA'fe- . 7-k>NDU-�NDU Mex1c �- Gll1!.IL_ HONOU ,-.HON� HO,�Q.U (b)(7)(C) I certfty con b)(6); Name.ndlll {1) • Show 80 8G -71-r-8G MC N N Crlmln.al HiG!ory M·- Nf ��-·,...:_--- �g-� e-i- NC M N 1115al� ·:��-- .::--NO ,� "'Ne NC M NC Ms :M NC NC NC NC NC NC NC .. M �- M M M - c(ese. Level LO ti--- N N N N N H LO Ill ·--NN __..,_ u'i- --·- (2} • Show medi 021 eoru:ll�cns, l\igh rlsk, fil 9111. risk, epileptic. ins 11!1&, e\c.. Use I sep"'81e line fur each l)llr;;on tr11ntferr�. This rorm la lo be axeCU1ed In sufflclent n1N11ber ol ccpl!,$ to allow receMng otlloerto retain oae CDJIY of his �I �e voucher end two lddlllonal copies for 6tal!on of flnal dell�ty. Signature: PIHCeandDele: 2020-ICLl-00006 1176 · -·"-r Comments (2} 381!i278�- LO - _,,...,_ -· _,_.,,_, LO LO LO 1.0 ---·-· - ----· ,__1,;9__ :---· b)(6), (b)(7)(C) 11tle: Subject IC (b)(6); (b)(7)(C); (b)(7)(E) Contact Number(&); whelher NTA or Flt131 Oroer '/0) 1 --•-•-·-R- ···__ 1 tas1s1s -tg-. t-·......-,_-- -..:1§- ----·- _:_:�-N--N Fine# (b)(6), (b)(7)(C); (b)(7)(E) .._.,LO • ._ N'""·-·.--t} To··· N MODE: Other: _____________ fer Slanr:taras and IC/! Air Boarding , equlrements for tnts ICE Air/Cf,orter movement :e; 11,naref'u•n�1eror .....�,1u-y,,<� .. ru,- __ ._ ............ 8G ~aG-· NC Glll'lg Memberahl!> N N Sex 8G __ M 13 _ ·--�·- - Transfer Oate: ___o_5/_1o-"-f_18___ RECORD OF PERSONS TRANSFERRED I ---- LASALLE CORRECTIONS TRANSPORT,L.L.C. Transport Trip Log Paperwork .Facility Van D Car Vehicle number: . Start Leg Loaded At Bus bH6); (b)(7)(C) Present Male D Female Starting Mileage 0 Total Transport Officers Loaded · Total On Male Male Female Female Total Total Date End Leg Unloaded at Money Yes D g �rty t] res vle. --z..0 Loaded At �o?P3B /J Transport Officers (b)(6); (b)(7)(C) � tu Total On Male Total ·,C Female 0 Total Total c) 0 □ kd'No □ Yes @N� □ Medicine Yes_ ) \ i5 \ l� qef J) (__, Ending Mileage l'"3?i32-S"n @No Start Thoe Date IC�{ Date \ \\� � 1'.5 End Time l\?JP Total ZG Present Male a c) u Total Unloade Male (b)(6); (b )(7)(C) Date IStart Tiine Date ;---�- s\6� SLRDSC Transport Trip Log 2020-ICLl-00006 1177 0 Total 0 Time Total on Male c::, Female Female c_J Total cJ Ending mileage "f I c C) Total � Time ct ..-:=-,.-�:='(�,1=f.:..�..p,_':;Jr;..:i;�;�»� End Tone Total miles n, � CJ . .. ��:: !'")�:.;.,,,.����*ffl�.:t�!►-�·=t-f�4�1-��@.f.�-:'�W-ci��A.o�.��-':��:tr�f!:;!;�k""B-:-..\'!";¾:;f%t��1�-:c�w.���R�.::�"JtZ!1i ,;,t;}�:.l)��-���;�l�-:.:·�:�-.::.• � ������_:-:.",,��e..-i:- Transnort Officers Male 2-(3 Fem.ale Property r Ending mileage 0 End Leg Unloaded. at Money Yes 1·q 1- C) Loaded Male Male , l----....;..____ -1-----.,!_f _,.__1._,1_----i Female Female Fem.ale :End Ti'me Date vlo Female Total 1 Ending Mileage Start Time d Me--it.A1 0 Female C) d A Cr Starting Mileage Male Pr7- 0No ',L-___________J Present Male Present Unloaded Total on ,r,,A E::f"No (b)(6); (b)(7)(C) . Start Leg of Assigned Duty Type of vehicle D Page. · San Luis Regional Detention & Supp<=!rt Center Time LaSalle-Corrections West Sau Luis Regional Detention and Support Center \ J Transnort 50 Passent!er Bus Seatina Chart - (b)(6); (b)(7)(C) 2. 4. 6 8. 10. 12. � . ----;.' - s -1ls. -« - _,__ � 3( 32 3• 31 38./.4.,. v/1 ni,, 1, 11 4l (b)(6); (b)(7)(C) 41. 43. 45. 4' 4, 41 4 47. 49. � -----1(b)(6); (b)(7)(C) Bus# Destination/Route: Officer: Officer: - u 25. 27. 29. 31. 33. 35. 37. 39. � - 16 18 20 22 24 17. 19. 21. 23. · } -- (b)(6); (b)(7)(C) Officer: 2020-ICLl-00006 1178 - ); :+f//'T'-1 - ,-i_ . ,__ ,__ From: Sent: To: !AO-DOMESTIC MISSIONS 14 May 2018 14:34:17 +0000 b)(6); (b)(7 )(C) r Cc: Kb)(6); (b)(7)(C) '---:"-::-::---::-::---::-::--:--::-:-:-:=-:-:-:-:::-:-:---::-::--:-:::-===-:--:=-::--:-:-:-:-:::-:--;:::=:::::::::: :::::::::::;:::::;:::=====:::;---------'�#ELPABQ-COORD-NOTIFY;#ELP-EPC-DETENTION-SDD0;���)- (6_);_(b_)(7_)(_C)____� Subject: RE: streamlined transfer process Bed Space Request for Transfer to Cibola from SYS/POE (19 subjects) Good to go for the domestic mission on 5/15 (IWA-ELP). Thank you, l(b)(6); (b)(7)(C) Enforcement & Removal Assistant DHS/ICE Air Charter Operations 6335 S. Downwind Circle, (b)(6); (b)(7)(C) Mesa, AZ 85212 (480) 638-I\�!\�/;,�, �esk From: �(b)(6); (b)(7)(C) Sent: Sunday, May 13, 2018 1:26 PM To: l(b)(6); (b)(7)(C) (b)(6); (b)(7)(C) ; t !AO-DOMESTIC MISSIONS I: #ELP-ABQ-COORD-NOTIFY "Vb)/6) (b)/7)(C) �(b)(6); (b)(7)(C) #ELP-EPC-DETENTION-SDDO . #ELP-ABQ-COORD-NOTIFY <>dflp!ao la Bllow recclvl� offlc:eclQ relal� cr,11 eo(Tf of Ills pe{5011ai �� vauct,erend tw,;, addltlooa! copl"' 1w sla!lon afrLnal dtlnv.ty. �NOCIZOL Female Female ¢ ft Starting Mileage Total Total Total ft ff /f Date Sta.rt Time s/,'-'J,i l 23c' l·SD1fr;3 ,. Transport Officers (b)(6); (b)(?)(C) Female End Leg Unloaded at Money HTC Property rzfNo Medicine 0Yes Ending Mileage :250 '64 g .l2fNo Date End Time 5} I� }ti" Present Unloaded Total on Male J\.{a.Je 1 Female ,- Female /o Total Total � /5 Ending mileage ,¥ Female /f Total � Tune ·z_hv- 95 Pl3C> Male :::f:i�-:.:�<;.::";��p·.ft.o.'.��:;�·W;::S�E-®��i:::¥-����(:§'1����::::r.�:;.::�w�t-:'x�-7-::=i�:t'��P�-��:W.+::P.::�\0":M:if��·-�t;;�✓i=��>--�,;:t-1.:?i\�-�-.t,J'��-�-�;�-vf�--f.$._)_�����������N�;�.��-�-i-�������,�'i=�����--; Start Leg LoadedAt µy-c. Starting Mileage !!SO 8'i. t - Present Male Loaded Male TotaI0n � 13 13 1''emale Fem.ale Female fl> f5 Total Total 1.3 L3 Pf Total ff Transport Officers (b)(6); (b)(?)(C) Date - 5}1� 1l& - Male □ End Leg Unloaded at Money Yes - -t (.-P,.I} &-- . 0"°No □ Property Yes !2rNo Medicine OYes. Ending Mileage i50q33 £1No Start Time J 530 End Time Date sltll}tt /13t:J Present Male 1.3 Unloade Male 13 · Female· Fem.rue ft ff 13 /5 Total Total Ending mileage g_s Total on Male f1 Female f:1 Total /f Time � 1�� �:.':�··_t::.:�:.,i _ {���..::�::·��r.�:·� ('i:��W#¾'.::��!�1 -��-��f:�:':",�f.-�:f-�:=-���f(-��;¥.�xi:=»�w�;-��-;.��:�;:,;-;f.s.::�::-::���J.;-;.t:ii?¥:'i:®:��-�r�-:,.�-::�1t�-:t�•q:::}f;�-':tf:.-.::-��v.:g·�M.";:����,(f���J:'.=f-.=.::.��:::�:i-:::,�-:-i��-�c-"J:�1�.�;;#���q-.:Ntj "T'... .,,..,.4'!1nnr-r Offic-.ers (b)(6); (b)(?)(C) - Date sl JI.I 1to End Titne Total miles Start Tune Date ll3D 5 /,1.1ht /131) 11D Tune 5 \u SLRDSC Transport Trip Log _ 2020-ICLl-00006 ......... 1190 _ _ ------------------.. •..... LaSalle Corrections West San Luis Regional Detention and Support Center Transport 50 Passenger Bus Seating Chart I lJj(b)(6); (b)(7)(C) 3. 5. 7. 9. 11. 1� 1!t 17. JL.,.M"� L ... . 19. b)(6); (b)(7)(C) 21. 23. 32. 34. 36. 38. 40. 42. 44. 46. 41. 43. 45. 47. 49. Officer: Officer. �toe .. -rn (b)(6); (b)(?)(C) .. 48. so. I 1-krc.. . 20. 22. 24. 26. 28. 30. 25. 27. 29. 31. 33. 35. 37. 39. I 4. 6. 8. 10. 12. 14. (b)(6); (b)(7)(C) 16. (b)(6), (b)(7)(C) )(6); Bus# 1(�,117\/('\ Destination/Route: 2. Date: ·l Offi 5 /1<1/11 cer: Officer: 2020-ICLl-00006 1191 . ..... _. ............. --- ..-----·----···· ----��----�--- .·-·---·-·-·--· Detain. ORDERTO Detain (b)(6); (b)(?)(C) ' POUCH j I i. f. jHERNANDEZ (b)(6); (b)(?)(C) 8G ! i [ - i FINGERPRINTS 8G 8G I � 8G ! 8G )JEFFRY . AGE SEX 19 M M 24 M 18 M 33 M 29 24 M 26 M BG Z1 M BG 23 BG 8G 22 Signalure Detention Office,, Sherift, etc. (Receiving Officer) Forni 1-203 Phila. ,�, SAN WIS REGIONAL DET CENTER NO. NM'IE Manifest No. 722009 (oaae 1 of 2) NAME OF FACIUTY; TO: SAN DIEGO, CA Pleal!! detain or reJease lhe following ALIEN M M I l i l ! I ! i I i I Nature of Prcceedings BIRTHDATE NATIONALITY .Month/Dale/Year HONOU j b)(6); (b)(?)(C) HONDU HONDU HONDU HONDU ! j l I i 2/18/1985 � b)(6); (b)(?)(C) I HONOU I; GUA1E MEX.IC i GUATE . NUMBER HONDU - i j ! AUEN A206418141 ! ' ! i (b)(6); (b)(?)(C) Data 5/14/2011 i i ! i ! i j lO i LO LO LO ! i I LO ii PREVIOUS Criminal Hislorv NC NC NC NC Illegal EntJy LO i i NC LO i NC LO LO � j LO 1,, AM NC I i ' ! b)(6); (b)(?)(C) ! l i ! I f I' NC ! i � 1 ! ! PHOTO __. ANS NUMBER i NC � Oifedlng Action DEPARTMENT OF HOMELAND SECURrTY- US IMMIGRATION AND CUSTOIAS ENFORCEMENT 2020-ICLl-00006 1192 REMOVAL 17851616 i ! (b)(6); (b)(?)(C) i 7•; i -i ! � f i Date Station 5/14/2018 Detain ORDER TO NAME OF FACILITY: CIBOLA COUNTY CORRECTIONAL CENTER Nature of ProQledings REMOVAL PREVIOUS BIRTHDATE ALIEN �IIJ�NIIURi:::� 11.11 IUBER Criminal History TO: ALSUQUERQUE, NM Please detain or release !he following Detain (b)(6); (b)(?)(C) POUCH NAME NO. 8G 8G 8G 8G 8G 8G jHERNANDEZ 8G jJEFFRY (b)(6); (b)(?){C) FINGERPRINTS . AGE SEX 19 M 24 M 18 M 29 30 35 33 8G 24 8G 24 8G 26 Signature Detention Officer, Sheriff, etc. (Receiving Officer) FOITTI 1-203 Phila. M M M M M M M I ! � 1 - NATIONALrrY HONDU HONDU (b)(6); (b )(?)(C) HONDU I i ; f ! - HONOU GUATE HONDU HONDU ' ! ; 2/1811985 (b)(6); (b)(?)(C) HONDU HONDU l��el LO l � LO I i HONDU ! Manifest No. 722019 {page 1 of 2) ALIEN 1 (b)(6); (b)(?)(C) i NC � ! LO � LO NC ! NC i LO � I 1 NC � i i I j ; I LO LO J_ ..o i I i � !Degal Entry i I NC NC ri.M PHOTO 5/15/2018 17851616 (b)(6); (b)(?)(C) ! NC � 'i �i � ! Date irecting Action Date i ' NC LO � A206418141 . LO � i ,m, \U/\f /\'-'/ I NC Station 5/15/2018 DEPARTMEHT OF HOMELAND SECURITY- US IMMIGRATION AND CUSTOMS ENFORCEMENT � {b)(6); (b){?)(C) 2020-ICLl-00006 1193 Conducte DATE: --..M-:::-t'-,a,,--::c�-----' TJME: __.J.t,�';4------ T OL-L THIS DOCUMENT IS CONFIDENTIAL All or part of this report may be subject to the Attorney/Client Privilege and/or the Work Product Doctrine. CORECIVIC GENERAL COUNSEL OFFICE OF INVESTIGATIONS INVESTIGATION REPORT FORM NAME OF SUBJECT FACILITY: FSC CASE#: FACILITY CASE #: PRIMARY ALLEGATION: Cibola N/A [bl(7}(E) I Death of a Detainee/Natural Causes/Illness (b)(6); (b)(7)(C) To: b)(6), (b)(7)(C} From: L------------1 Date: May 29, 2018 I EXECUTIVE SUMMARY: ,,.,....,,...,.., ,On May 25, 2018 �tb-)(6); (b)(7=)(=c) assigned me to check policy compliance of the intake procedures and medical transport of Detainee Jeffery Hernandez #206418141. ---,I INVESTIGATION: During the investigation I checked the intake paperwork, OMS, and reviewed the Milestone camera footage to determine if all our policies and procedures were followed. Detainee Hernandez arrived at the facility on May 16, 2018 at 2043 hours via Transcor I and transport. During the investigation l interviewed the intake staff both (b)(6); (b){7)(C) stated they called medical and made phone notification of the transport at kb)(6): (b)(7)(C) I about 2130 hours. The booking process was continuous for detainee Hernandez and was completed at 0112 May 17, 2018. A nurse was notified and was in medical to get the paperwork for the transport at 2241 hours May 16, 2018. At 0221 hours a group of the detainees was moved from intake to medical and were secured in the medical waiting area. Page I 1 Proprietary Information - Not For Distribution - Copyright - Property of CORECIVIC 10/2015 TOOL- THIS DOCUMENT IS CONFIDENTIAL All or part of this report may be subject to the Attorney/ lient Privilege and/or tbe Work Product Doctrine. At 0600 that group of detainees was served breakfast in the medical waiting room. At 0726 detainee Hernandez was called out of the waiting room by a nurse to begin his medical intake process. At 1100 hours detainee Hernandez was sent out on medical transport via facility vehicle. I On May 25, 2018 Sl5l(b}(6); (bl(7l(Cl went to the morgue in Albuquerque where she took photographs and fingerprints from detainee Jeffery Hernandez. The fingerprints were taken at 1030 hours. At 0908 hours Records Manager j(b)(6); !Completed an inventory of detainee Hernandez property in an effort to find next of kin information. One phone number was found and given to ICE King. CONCLUSION SUMMARY: Based on this review of the intake procedures it appears that our policies and procedures were followed correctly. The detainees were moved from intake to medical at 0221 hours and detainee Hernandez was seen at 0726 hours. EXHIBITS: 1; (2) fingerprint cards, one for each hand. 2..,_· .w.u........��.......----, (b)(6); (b)(7)(C) Page I 2 Proprietary Information - Not For Distribution - Copyright- Property of CORECIVIC 10/2015 Declaration of Next-of-Kin I, j(b)(6): (b)(7)(C) I an adult of sound mind and body, freely and do hereby make oath and state under penalty of perjury of the laws of the United States of America pursuant to 28 U.S.C. § 1746 that 1. 2. 3. 4. I am the sister and next-of-kind of Roy Alexander Hernandez Rodriguez, born 2/18/1985, al o known a Jeffry Hernandez. I I am represented by attorney Kb)(6); (b)(7)(C) and his law firm, The Law Office of ](b)(6); (b)(7)(C) of a hville, Tennessee PO Bo 90568 ashvill.e 37209. By thi Declaration, I expressly authorize Mr. l(b)(B); land his agents to communicate and receive information on my behalf I I hereby formally request that l(b)(6); (b)(7)(C) perform an autopsy on my sister. I hereby request access to and copies of and, on behalf of my sister as her legal representative and the putative heir to and administrator of her estate, authorize the relea e in full of any and all records and infonnation of or regarding my sister to The Law Office ofl(b\/6\: /b\/7\/C\ lor tol(b)(6); (b)(7)(C) such records and information to include but are not limited to any and all of the following types and subjects of records and information: medical; psychiatric; mental health; addiction; drug and alcohol; communicable disease; treatment; therapeutic; counseling; psychotherapy; genetic; HIV/ IDS; prescriptions; autopsy; death; testing and laboratory results; criminal; arrest; detention; educationai legal; familial; governmental; disciplinary; photographs, images, and recordings; and physical samples. I Attestation I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct. Executed on � / l ◊ l f, (date) by � b)(6); (b)(7)(C) Printed (b)(6); (b)(7)(C) amej l Translator Attestation I hereb cer that I (b)(B); ( and every wor translation. of etjui-y under the laws of the United States of America pursuant to 28 USC 1746 am fluent in Engli hand panish and th.a I ha e accurately translated each e oregomg ocument from En lish to S anish to the Declarant, and that she understood this (b)(6); (b)(7)(C) by ___----i___________..r-----(b)(6); (b)(7)(C) Pnnte . d N rune: _j ------------� 2020-ICLl-00006 1196 OcoreCivic Date 5/17/18 5/17/18 Transport Officers I b)(6); b)(7)(C) Date: Time: Office: Location: I Depart time /200 ESCORT TRIP Arrival Time Destination tLc,.S- {', �/4. (!7<,,-'4. Apointment 5/17/18 Emergency Depart time Arrival at Facility / / Total Hours At Destination / Total Miles i/. '$!.. Cibola General Hospital Grants, NM INMATES/DETAINEES Hernanadez, Jeffry 900- 2020-ICLl-00006 1197 ICE--TG � CoreCivic 1 nm al Name & 111 m bcr# ---=-l_'=f = G_//4"-''("--/.-'-"(l."""�"""""'oA e:.:a"'"'t,.,,c_,_: -"-0=5_,- l,._,7_-=. 81 '-'<:""'z..�J�e.=-J.{f_,_,.("--;�D E If J orr ti a l i n lak n Tran port v hicl con a1n C11rr nl 9-100, 9-10 Policies Tran port v hicle con lain current 1 3 4 5 lnmat 6 Pre Equipment i bullet 1roof R1111 a ·nrr nl PPlO, verif'y if' tatu i ued or cliang cl. (Cii\l Ca e) 7 Th inmate ha 9 LO ]l (Proper amount or Laff a · fied cl) EHJCLE # __G�--- TOT L TRIP M TL PHJ 1AR. RO TE: ___eA -=------- Tran ·port me r #l Tran. I' rt f'licf'r #2 Tran. port fficer #3 Transport Offic r # b rvino­ up rvisor (b)(6); (b)(7)(C) l (b)(6); (b)(7)(C) J ----==--=-­ am c Print Nam/' {/ Gh: _____ ECO D,:\ HY HO TE: ---.!!:B:..-___ igna LUl'S.., ignalur .--- 05-17-18 Date 05-17-18 Dat Print 'arne igna Lure Dal' Print jr,na Lur' D.itc (b)(6); (b)(7)(C) anrn Print Nam igna ture 2020-ICLl-00006 1198 EQUIPMENT CHECKLIST EQUIPMENT (check all applicable) Transport Packet (Containing: Transport Order (9-18E) Escape Flyer (mass court transport only) Current Photograph - if no escape flyer 9-18B, 9-18C, or 9-180 (if applicable) Cell Phone Inmate/Resident Roster Cell Phone Charger Ballistic Level 3A Protective Vests Oleoresin Capsicum (OC) Metal Detector (hand-held) Emergency Binder (containing): 1. MAP: (Marked with local airports, hospitals, and county jails within the normal transport routes) 2. Phone Numbers & Physical Addresses: (of airports, hospitals. and county jails marked on the map) 3. Local Police & Sheriff List: 4. Emergency Phone Numbers Transportation Post Orders Transport Site Survev (9-18H) Transportation/Mileage Logbook Current Insurance Card Current Registration PRESENT ✓ � / v ✓ ✓ ✓ ✓ ✓ . ../ ./ V ../ \../ ✓ v ✓ Full Restraints (two complete sets) Flex Cuffs (= to vehicle occupancv) Inflammatory Agents (foam only) Firearms COMMENTS: ✓ Fire Extinguisher (fullv charged) Disposable Camera I 11•.l�l\T / ../ First Aid/Bloodborne Pathogen Kit CONDITION �I\T / ✓ Flashlight (operable) Tire Changing Equipment N/A 9-18H V ✓ ✓ ✓ ✓ Equipment Check Conducted by (Name & Title): V l(b)(6); (b)(?)(C) I Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 1199 7/10/13 / f � 'f ��DRIVER VEHICLE INSPECTION REPORT I I Facility Name Cibola County Corrections Center Vehicle Make Ford I Vehicle Model b}(6}; (b}(?}(C} � Driver Printed Name I Beginning Mileage I I -:ltlc)a>-4- I t 35 0 I VEHICLE: IC: Place a ✓ to Indicate an inspection was completed or write NA if item is not applicable DD: Place a✓ io Indicate defects discovered and explain in "Defects Discovered Summary" section below PRE DD ✓ ./ ITEMS IC Brakes Operable Brake Lights Operable Head Lights Operable Turn Signals Operable Emergency Flashers Operable Tire Levels and Condition Acceptable Lug Nuts IC POST DD ./ ./ ✓ ✓ ✓ ,I Wheels and Rims I Date I VIN# Employee ID Ending Mileage ITEMS Horn Operable Steering Operable Rear Vision Mirrors Windshield Wipers Operable Fuel Level Acceptable Oil Level Acceptable Scratches/Dents Present Coupling Devices 8-12A 05/17/2018 I l(b}(6}; (b}(?}(C} �l2Z16 IC PRE DD IC t/ ,/ ,;/ POST DD / / / ./ ✓ TRAILER: IC: Place a✓ to indicate an inspection was completed or write NA if item is not applicable DD: Place a ✓ to indicate defects discovered and explain In "Defects Discovered Summary" section below ITEMS IC Brakes Brake Lights PRE DO IC POST DD Head Lights Turn Signals ITEMS Rims Air Line Connections, Hoses, Couplers IC PRE DD IC POST DD King Pin Upper Coupling Device Rails or Support Frames Emergency Flashers Tires Tie Down Bolsters Sliders or sliding frame lock Lug Nuts Wheels Locking Pins, Clevises, Clamps, or Hooks SECURITY & MISCELLANEOUS: IC: Place a ✓ Lo indicate an inspection was completed or write NA ii item is not applicable DD: Place a ✓ to indicate detects discovered .iill! explain in "Defects Discovered Summ_ar�y_" _se_c_tio_n_b_e_lo_w_________� ----�----� ITEMS IC Security Screen Secure Contraband Search - If found, explain below Interior Clean PRE DD IC POST DD ITEMS Emergency Equipment Present Lockln Devices Operable Driver Possesses Llcensu re IC PRE DD IC POST DD •1F ANY OF THE ITEMS ARE FOUND INOPERABLE OR CONSIDERED A SAFETY HAZARD., NOTIFY THE SHIFT SUPERVISOR IMMEDIATELY." DEFECTS DISCOVERED SUMMARY: /f/4AK c/2�a./ CONTRABAND DISCOVERED SUMMARY: Driver Signature (b}(6}; (b}(?}(C} THIS SECTION TO BE COMPLETED BY MAINTENANCE/REPAIR CENTER PERSONNEL ONLY: NOTE: Repair Center personnel may provide a receipt outlining work completed in lieu of signing this form. Choose One: D Defects noted above have been corrected COMMENTS: OR D Defects noted above do not need to be corrected for safe operation of the vehicle I Title Printed Name 01/02/13 Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 1200 I FACILITY: ] DATE OF TRANSPORT: TRANSPORT ORDERS 9-181: I CIBOLA COUNTY CORRECTIONAL CENTER J 05/17/18 MASS COURT TRANSPORT: [XI NO D YES If yes, attach Escape Flyers and complete Sections Ill & IV only of this form. SECTION I - TRANSPORT LIST (To be completed by the Records Department or other department as identified in policy 9-18)· Housing Height Criminal Charge or Custody I.D.# Date Inmate/Resident Name Assignment Conviction (highest current Classification Of charge/conviction) Birth Hernandez, Jeffry R01 002 206-1181-1! 02/18/1985 I TOTAL NUMBER OF INMATES/RESIDENTS ON TRANSPORT: TRANSFERS: (Any permanent transfers to other facility or agency?) ALERTS: (i.e. escape risk, combative, etc) Inmate/Resident Name Hernandez, Jeffry YES-0 NO-[XI I NO- □ Inmate/Resident ID# 206418141 5'3" Low Purpose of Transport (i.e. court, medical, transfer, appt, etc.) Medical 1 01 If "YES", the Records Manager (or other designated department) will ensure the inmate/resident's institutional file and Medical file are trans orted with the inmate/resident. YES-[XI If "YES", complete section below. ALERT Comment: New Intake b)(6); (b)(?)(C) DATE: 05/1712018 *If additional space is needed to accommodate inmates/residents on this transport, this page may be duplicated / copied. The Transport Supervisor will ensure to number all pages accordingly when reviewing the Transport Order. Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 1201 7/10/13 PAGE OF 9-18E TRANSPORT ORDERS SECTION II - HEALTH SERVICES (To be completed by the Health Services Department): Are any of the female inmates listed in Section 1 currently pregnant? D Yes [ZI No (If yes, list below and include any special instructions) Special Instructions: (e.Q. medications, physical limitations, special needs, etc.): Inmate ID# Soecial lnstructions/Reauirements: Inmate Name Ix l(b)(6); (b)(?)(C) QHCP Printed Name If requesting reduced restraints ror memcaI purpose, must be signed by HSA or Physician also: I I QHCP Signature Printed Name & Title I I Kfb)(6); (b)(?)(C) r ::signature >·17-/� *Note: If special medical instructions are listed above, the Transportation Officers will be responsible for meeting with the Health Service Department prior to the transport. SECTION LI I - TRANSPORT REQUIREMENTS (To be completed by the Transportation Supervisor): I VEHICLE REQUIREMENT (i.e. bus, van, etc.): I Van I NUMBER OF TRANSPORT OFFICERS REQUIRED/ASSIGNED: I CHASE VEHICLE REQUIRED: I NO-� I YES- □ MEALS REQUIRED (if the transport lakes place during meal time): NO-� YES-0 [ 2 lf"YES', NUMBER OF CHASE VEHICLE OFFICERS ASSIGNED: I If "YES". the Transportation Officers shall be responsible for obtaining sack lunches for all inmates/residents and em lo ees. SECTION IV - AUTHORIZATION: TRANSPORT SUPERVISOR Assistant Shift Su ervisor or above DATE: 05/17/2018 *The Transport Supervisor will ensure to number all pages accordingly when reviewing the Transport Order. WARDEN/ADMINISTRATOR OR ADO {if not available for sionature, note the Date & Time aooroval received) DATE: Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 1202 05/17/2018 7/10/13 PAGE OF TRANSPORT ORDERS 9-18E SECTION IV continued - AUTHORIZATION: Additional instructions and/or comments from the above authorizing staff only: Use proper restraints required. Unscheduled Appointments: In the event a non-emergency transport is required with minimal or no prior notice, the highest-ranking official will coordinate the transport, to include notification to the Dutv Officer prior to the transport. Date/Time: Authorization Received by: I I I SECTION V - TRANSPORT OFFICERS ACKNOWLEDGEMENT Transport Officer Signature: Printed Name & Title: Transport Officer Signature: Printed Name & Title: (b)(6); (b)(?)(C) Transport Officer Signature: Printed Name & Title: Transport Officer Signature: Printed Name & Title: I I DATE: I DATE: I DATE: DATE: Proprietary Information - Not For Distribution - Copyrighted - Property of CCA 2020-ICLl-00006 1203 I 5 - I 7- /,,r I 7/10/13 PAGE OF Facility Name Location of Post Date Cibola County Correctional Center [,l,i.,{4 (1.fr•�uf �fP,kf �� 17. 1e_r�on ,Role Witness �\,f'\ Housing Location (For Inmates/Residents Only) - ,,, I .,,, Based on your .knowledge, what di� yoy:,�ee, hear, and go? On May 25, 2018 I Senior OfficerKb)(6); I was posted Hospital Duty at Lovelace Medical Center Downtown with Detainee Hernandez, Jeffry# 206418141. At 0332HRS �(b)(6): (b)(7)(C) witnessed Nurse Practitionerkb)(6); (b)(7)(C) -Call time of-death for Detainee Hernandez. At 0333Hrs Shift-�(b)(6); {b)(7)(C) I were notified Via cellphone. 0430HRS Kb)(6); .h advised the body will be cleaned and transferred to the morgue. At 0456HRS Nurses enter room to get body ready to be transferred to the morgue. 0525HRS nurses complete bagging body, Waiting on Security to take body to the morgue. At 0547HRS Security on site to take body to the morgue. At this time We exited the 7th floor with Detainee Hernandez body enroute to the morgue. At 0551 arrived at the morgue !was Witnessed security staff put detainee Hernandez body into the morgue fridge #3. Shift lilJl(§l fblf7\rc, Notified. End of hospital duty. End of Report I I Did you receive any injuries? YES or NO (If YES, Explain Below) I No I Were you evaluated by medical? YES or NO ! No Printed Name: , (b){6); {b)(7){C) Signature: Typ�d By: I Date� I Date: ' May 25, 2018 May 25, 2018 This section to be completed by CCA staff if the civilian/other or inmate/resident refused to complete the 5-1 c. Place an "X" in the appropriate box: Inmate/Resident refused to complete this 5-1C Civilian/Other refused to complete this 5-1C Employee/Witness Printed Name Employee/Witness Signature Date: Employee/Witness Printed Name . Employee/Witness Sign�ture Date: 9/2/08 Page 1 of 1 Proprietary Information - Not For Distribution - Copyrighted 2020-ICLl-00006 1223 Property of Corrections Corporation of America 5-1C INCIDENT STATEMENT I 1nc1de.nt Number I Facility I Cibola County Correctional Center I lnciC,ent-.D�te , I 6/2157I r- I I Incident Time (HRS) IQ"J3'2 ID Number § Housing Location (For lnmates/Resident Only) J(b)(7)(E) Pers_on Type Person Role I I· Did you receive any injµri�s? 'YES or�))f YES, Explain Below) I No yo4 evaluated t>y medical? YES o No Print�d Name: · (b)(5J; (b)(?J(CJ Sig�ature: Typect By: Dale: Date: Place an "X" in the appropriate box: Inmate/Resident r�fuse_d to ccimplete•tf.lis 5-1C Civilian/Other refused to complete this1;-1C Date: E·mpto.yee/Witness Printed Name .Erpployee/Witne�s Signature I Date: I 9/2/08 Page 1 of 1 Proprietary Information - Not For Distribution - Copyrighted 2020-ICLl-00006 1224 Property of Corrections Corporation of America 5-1A INCIDENT REPORT Incident Number: Facility: Cibola County 05/25/2018 03:32 hours lnciuent Date/Time (HRS): I Facility Damage: !Incident Location: ! l(b)(7)(E) None / Offsite INCIDENT PRIORITY LIST: Priority ! I "· Priority Description - Death-Inmate/Resident-APPARENT NATURAL CAUSES Other Priority De cription: DESCRIPTION OF INCIDENT: On May 16, 2018 at 2315 hours ICE Detainee Hernandez, Jeffry# 206418141 was processed into Cibola County Correctional Center as a low level Detainee. Hernandez is a 33 year old Trans gender from the country of Honduras. On May 17, 2018 at 1121 hours detainee Hernandez was sent out to Cibola General Hospital via facility vehicle for further medical assessment. At 2118 that same day Hernandez was air lifted to Lovelace downtown Albuquerque. Hernandez remained at Lovelace until May were notified. 25 2018 at 0332 hours when she was oronounced dead of natural causes. l(b)(6), (b)(7)(C) I I Yes INVOLVED PEOPLE: Inmate/Resident ame(s) & NlllDber JEFFRY HERNANDEZ (206418141) Employee Name(s) & Number (b)(6); (b)(7)(C) I Medical Evaluation Completed? I Jud diction Witness or Participant 5-1 C Attached or Refused'! Injuries ICE Participant Refused N/A · 5-lC Employee Title Witness or Participant Attached? DETENTION OFFICER Witness Yes NIA SR DETENTION OFFICER Witness Yes N/A Injuries N/A HEALTB SERVICES PERSONNEL CONDUCTING EXAMINATIONS: Page 1 of 3 Proprieta,y lnfo,mation - Not For Distribution - Cqp_yrigtiwJ:.1 - Property of CoreCivic 2020-ICLI-000uo 1 Z,:'. 5 10/03/13 5-1A I INCIDENT REPORT Weapons Discovered? IW jweaporrDesedption How Many? NIA Inmate/Re ident Disciplinary Charges Filed? Inmate7Resident Name(s) & umber l N/A Incident Videotaped? --- Name/Title of Camera Operator: I ··�- ····- If Not Recorded, Explain: ·-· I amerfitJc of Photo Taker: I j No Chain of' Custody Maintained: Criminal Charges: No -· Property In ·entory Completed I How Man:r? - j 1 I NIA IN/A I Name/fitle of Person Discovering Evidence: I .. information Sheet Evidence reco ered during incident? Evidence Current Location: - I EVIDENCE INFORMATIO I - Segregation and/orPHD Photos of injuries, contraband, or property? Evidence Description: apon Loc_ation_� N/A Cell Phones Discovered? If No Photos, Explain: lnowMaoy?. I Notifications: Facility Notifications: Person_N otificd Dateffime Notified Notified By b)(6), (b)(l)(C) 05-25-18/0332 b)(6), 05-25-18/0351 b)(?)(C) ADO? No Yes F C Notification : Page 2 of 3 Proprietary Information - No20 8�rtt.Y�6 pyr� • Property of CoreCivic M6g � 10/03/13 5-1A INCIDENT REPORT t Person,Notified (b)(6); (b)(7)(C) Dateffime Nofified I Notified By I 5-25-18/345 (b)(6); (b)(?)(C) Date/Time Notified - Notifie� By Contracting Agency Notification : Person Notified r )(6); (b)(7)(C) 1 I 05-25-18/0336 l\�>(6);lf - Dateffime Notified Notified By � -, Outside Agency Notification : Referred for Investigation b Warden/Administrator or ADO? (b)(6); (b)(7)(C) Prepared By: Completed Date/Time: amc l(b)(6); (b)(7)(C) Page 3 of 3 I Title: Yes Shift Supervisor 05/25/2018 05: 14hours Job Title Date and Time Signed SHIFT SUPERVISOR 05/25/2018 06: 11 hrs. 2 Proprietary Information - No':f6 8�,'e'rll!ijtJcfcffl>Yr��f- Property of CoreCivic 10/03/13 l(b}(6}; (b}(7}(C} From: Sent: To: 8 Jun 2018 21:32:03 +0000 (b}(6}; (b}(7}(C} Cc: Subject: FW: Preliminary Autopsy Findings Good Afternoon, Just received the message below. I �b}(6}; (b}(7}(C} Assistant Field Office Director ERO El Paso Field Office 915-856-rb}(6} office) 915-726- '... ·-· ( cell) Frederick.T .Hernandez@ice.dhs.gov I( From:l(b)(6}; (b}(7}(C} Sent: Friday, June 08, 2018 2:48 PM b}(6); (b)(7}(C) Subject: Preliminary Autopsy Findings Good afternoon, The chief pathologist from the Albuquerque Medical Investigations Office called me with the preliminary findings of Mr. Hernandez Rodriguez autopsy (Death while in custody- Cibola) Finding consistent with someone who is HIV and not receiving treatment, and consistent with the earlier CT body scan and external examination Lungs were heavy and solid; probable infection; pending microscopic examination; exam may show pneumocystis pneumonia associated with HIV Spleen and chest lymph nodes were enlarged; microscopic exam pending Small shallow ulcer in esophagus; microscopic exam pending; maybe caused by herpes which is seen in HIV detainees Detainee had large amount of diarrhea and sections of the intestine are pending microscopic exam; stool send for culture The brain was maintained intact for further study There were no signs of abuse or injury. 2020-ICLl-00006 1228 Body will be released to outside MD for a 2 nd autopsy arranged by the detainee's attorney. (Once ICE approves it) Please contact me if there are any questions. Respectfully, !(5); (b)(?)(C) I corrected to May 15, 2018 by subsequent email. Note: As detailed below, the first complete medical evaluation of HERNANDEZ after she was picked up at San Ysidro was at CCCC, 56 hours after she entered ERO custody. She passed through the San Luis Regional Detention Center and El Paso Service Processing Center (EPSPC) before being transferred to CCCC. May 14, 2018 By email timed 10:34 a.m., Gary Gates, ICE Arr Charter Operations, approved transport from the Phoenix-Mesa Gateway Airport to the El Paso Airport on May 15, 2018. According to Byoung Park, SDDO assigned to the ERO San Diego Field Office, LaSalle Corrections transportation officers for the San Luis Regional Detention Center (SLRDC) picked up HERNANDEZ and 18 other transgender detainees at the San Ysidro Point of Entry at approximately 12:00 p.m. Their transport was requested by email the day before. The detainees arrived at SLRDC at 6:00 p.m. and according to Assistant Field Office Director (AFOD) \�(\�\--, (�:\�:ir \ were placed in a holding cell. He reported that because their departure was imminent, the detainees were not medically screened. Asked whether ERO was aware of any medical information received from CBP when HERNANDEZ's custody was transferred, both AFOD l' Yes � }f6' Yes Does the patient show signs of depresslon/emollonal llatness/aying/arudety? If yes, to any to the above -4 questions. explain Prison Rape and EllmlnaUon Act - Next 8 questions Yea reeDonses should bo referred to classlRcatlon for further evaluation/housing decisions. 11 Have you been approached for sex or been a victim or sexual assault whlle Incarcerated? Yes 21 Have you been a victim ol unwanted homOSCJCuality? Yes 3! Are you concerned about being sexually assaulted or abused while incarcerated? Yes Explain I exp1a1n I E>cpress that they are. or Is perceived lo be: unable to protect self in prison.1ail; will be picked on or 6 bt.Jllied b other inmates· arance? or is small size under S'B thin ild under 130 unds} frail or outhful a Explaln Yes 7 Developmentally disabled. confused/cfisoriented? Yes 8 . Other problems not addressed above? Yes Explain Explain Descrlpllon of lnJuries/ObJectfveObservations: 1 Brufse/s: 2 Contusion/redness: 3 Laceratlon/s: 4 lncislon/s: 5 Soreness: 6 Swelling: Nedi Should..,. Elbow for«ilrao llaod J Other: f'6- SIJ'll'eS �t¾r.uj A a,-;(/ W61;v 1f,16 �T ;'J?,?Nl71 4"1f> A �t-F. Kact Your Rla:t,c S"od< Your Rlpt Side '--�-----------------� ..•.•....... Disposition: (Check asappropriate) j .. Fool Froac General population Suicide watch Lower level Lower bunk Mattress Referral to medical provider Referral 1o mental health Negative pressure room Referral to external health care facility (Facility name): (b)(6); (b)(7)(C) Signat---"T"ff'---� b)(6); (b)(7)(C) .. , RN Dale/Time CJ? have I, the undersigned, affirin that the above information is correct to the best of my knowledge. In addition I bee� provided in{qrmation verbally, and In writing on how lo access medical, den��l. and mental health services at the facility. (/ • V,t? �l �t-rl� Detainee Speaks English Y or if)_ Staff Speaks Detainee's Language:@>r N Language Spoken: �¾�d ,.Djd you use interpre b)( C!_yr N Name/Nu MAY 1· 7 2018- . �� TI� 073£ Effective Dat.e: 8115120111 Revision Date: 4/22J2Q13, 6, A206418141 HERNANDEZ, JEFFRY DOB: 02/18/1985 M ARD: 05/16/2018 CCCC/MILAN, NM 87021 l(b)(6); (b)(?)(C) From: 5 Oct 2018 19:54:37 +0000 Sent: l(b)(6); (b)(?)(C) To: HERNANDEZ draft HERNANDEZ Draft Report 10.05.18.docx Subject: Attachments: Good afternoon, (b)(6); . was grea ti. ,h,n,,,.... , h ope your t np Attached is the completed initial draft of the HERNANDEZ DOR (SharePoint is acting up today so the version there is not the most recent - I will update by COB if it starts to cooperate). I'll put together the rest of the package next week. Apologies if there are typos or some passive voice scattered throughout. Wanted to get this to you ASAP so you could potentially review before I depart. CC has already responded to the couple questions I had. We are still pending death certificate and autopsy reports (don't even have official prelim) but ERO lis following up on this again for me. l\�!\�/;, 0, Thanks! !{b}(6} (b}(7}(C} Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Washington, DC 20536 Cell: (202) 270�\P(\2(;, !(b)(6); (b)(?)(C) I 2020-ICLl-00006 1279 Page 1280 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1281 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1282 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1283 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1284 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1285 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1286 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1287 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1288 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1289 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1290 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1291 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1292 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1293 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1294 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1295 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act From: Sent: To: Subject: l(b)(6); (b)(?)(C) 11 Dec 2018 20:42:40 +0000 l(b)(6); (b)(?)(C) I Please email it to me - Detainee Death Review - Jeffry HERNANDEZ Will you please email it? I've been breathing heavily down CBP's neck on this one. Yesterday I officially made them sick of me, I think. Thank you. l(b)\�);.I Froml(b)(6); (b)(?)(C) Sent: Tuesday, December 11, 2018 2:52 PM To: Asher, Nathalie R J(b)(6); (b)(7)(C) Davis, Mike P <(b)(6); (b)(7)(C) (b)(6); (b)(7)(C) *b)(6); (b)(7)(C) I>; Padilla, Kenneth i{b\/6} {b\/7}(C\ (b)(6); (b)(?)(C) Subject: Detainee Death Review - Jeffry HERNANDEZ Disseminated on behalf of!, bl/6): /bl/7l/Cl ) 7( )( ) (b)( ); J C ;;============.:::;:--:--;-----::---:--;::::::::;=::::::;;:::::::;:========:::::::..:..:..,ennings, David W "-: ;;: .,.,.=6 ;;(...,,b= :;: ;; ;::;:; � Loiacono, Adam V �, Johnson, Tae D , #ICE DD STAFF ; Padilla, Kenneth /h\/R\· /h\/7\/r'.\ (b)(6); (b)(7)(C) Subject: Detainee Death Review - Jeffry HERNANDEZ Disseminated on behalf of J(b)(6); (b)(7)(C) Professional Responsibility... l Unit Chiet External Reviews and Analysis Unit, Office of Good afternoon, The ICE Office of Professional Responsibility, External Reviews and Analysis Unit, has completed the Detainee Death Review for Jeffry HERNANDEZ. HERNANDEZ, who was in U.S. Immigration and Customs Enforcement (ICE) custody at the Cibola County Correctional Center in Milan, New Mexico !NM), was pronounced dead on May 25, 2018, at Lovelace Medical Center in Albuquerque, NM. HERNANDEZ's preliminary cause of death is cardiac arrest. Autopsy findings and a certificate of death were pending as of the date of this report. 2020-1 C Ll-00006 1341 The memorandum announcing completion of the review, the final report, and the exhibits can be found HERE. If you have any questions or wish to further discuss the findings, please contact me. Thank you, l(b)(6); (b)(7)(C) Unit Chief, External Reviews and Analysis Unit ICE Office of Professional Responsibility 202.732 (desk) 202.907 (mobile) i�\i�\( 2020-ICLl-00006 1342 l(b)(6); (b)(?)(C) From: 9 Aug 2018 13:28:25 +0000 Sent: I l(b)(6); (b)(?)(C) To: Subject: Attachments: FW: EADM - Hernandez EADM - Hernandez.pdf FYI She was at San Luis from May 13-15. Sent with BlackBerry Work (www.blackben-y.com) From:l(b)(6); (b)(7)(C) Date: Wednesday, Aug 01, 2018, 3:20 PM To: 1(b)(6); (b)(7)(C) Subject: EADM - Hernandez Please see attached. According to EADM: • On May 13, 2018, at 11:18 a.m., the detainee was booked into the San Diego office's custody. • On May 15, 2018, at 12:00 p.m., she was transferred to El Paso SPC. • • • On May 15• 2018, at 3:15 p.m., the detainee was booked into El Paso SPC. On May 16, 2018, at 8:00 a.m., she was transferred Cibola. On May 16, 2018, at 10:47 a.m., she was booked into Cibola. Let me know if you would like more details, l(b)(6); (b)(7)(C) Management & Program Analyst External Reviews and Analysis Unit ICE, Office of Professional Responsibility 950 L'Enfant Plaza, SW Mail stop 5501 Washington, DC 20536 Desk: (202) 73 (b)(6); (b ) C Cell: (202) 270- )(? ( j(b)(6); (b)(7)(C) 2020-ICLl-00006 1343 EADM Detention History Page 1 of 1 EADM Current I Active Alerts Detention Loca�on: HOU - HOUICDF A$signed Bed: NIA Type: R • Released Local Code: NIA Treat As Juvenile: No Detention Classification: Low Attorney Notified: No I I I Transgender Detention History F.O. of Removal [ Criminal _J Hernandez, Jeffry 206 418 141 HistoryDetention History for JEFFRY HERNANDEZ I I FILTER BY ENCOUNTER/ SUBJECT 10 FILTER BY CURRENT/ HISTORICAL RECORDS FILTER BY CASE NUMBER custody) I � Show Current Detention Records (currently in I Book In USM Date I I I I � Show Historical Detention Records A-Number Subj � ID Case# b)(7)(E) Detention Location Book Out Date CIB - CIBOLA COUNTY CORRECTIONAL CENTER 05/25/2018 0332 Released - Died Release / Book Out � 05/16/2018 1047 206 418 141 0511512018 1515 206 418 141 EPC - El PASO SPC (IHSC) 05/16/2018 0800 Transferred - EPC 05/13/2018 1118 206 418 141 SND - SAN LUIS REGIONAL DET CENTER 05/15/2018 1200 Transferred • SND 03/0712014 1709 206 418 141 HOU - HOUSTON CONTRACT DET.FAC. (IHSC) 03111/2014 Released • Removed 03/07/2014 1707 086 859 115 HOU • HOUSTON FO HOLDROOM 03/0712014 1708 Transferred - HOU 05/1412009 1700 086 859 115 DAL • ROLLING PLAINS DETENTION CENTER 05/15/2009 0649 Released - Voluntary departure - I 1131 I I Records with the USM indicator signify detainees that are under the custody of the U.S. Marshals but are detained by ERO. United Stales Department of Homeland Security (OHS), U.S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO) I Release EARM 5.50 l(b)(7)(E) 2020-ICI I-QQQQ6 1344 8/1/2018 From: l(b)(6); (b)(?)(C) To: !(b)(6): (b)(?)(C) Sent: Subject: Attachments: 18 Oct 2018 16:29:34 +0000 ! FW: HERNANDEZ DOR HERNANDEZ Draft AD Memo.doc 2020-ICLl-00006 1345 Page 1346 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act Page 1347 Withheld pursuant to exemption (b)(5); WIF Draft of the Freedom of Information and Privacy Act fb)(6); (b)(?)(C) From: Sent: To: Subject: 14 Dec 2018 14:07:53 +0000 !(b)(6}: (b}(?)(C) FW: OMI 2018-03102 Hernandez Rodriguez ! FYI Kb)(6); (b)(?)(C) Section Chief ERAU-OPR-/CE From: !(b)/6): (b)(?)(C) Sent: Friday, December 14, 2018 8:53 AM To�(b)(6); (b)(?)(C) Subject: FW: OMI 2018-03102 Hernandez Rodriguez FYI Sent with Black Berry Work ( www. bl a ck berry. com l From: l(b)(6); (b)(7)(C) Date: Thursday, Dec 13, 2018, 8:53 PM To:rb)(6); (b)(?)(C) Subject: FW: OMI 2018-03102 Hernandez Rodriguez The latest. Not sure if you already received this. l(b)(6); SDDO ICE Albuquerque 505-23S�(b)(B); I From: l(b)(6); (b)(7)(C) Date: Thursday, Dec 13, 2018, 11:33 l I (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) 2020-ICLl-00006 1348 Moore, Marc J r b)(6); (b)(?)(C) Subject: FW: OMI 2018-03102 Hernandez Rodriguez Good morning, Please see response from ME office in Albuquerque. and again and stressed the importance of getting the finalized report I also spoke with !(b)(6): (b)(7)(C) from l/h\/fi\ �SAP. I also asked if there can be a preliminary report released, which he stated he !He mentioned that most likely!(b)(6): !would not release a would take it up with l(b)(6);__ preliminary). I v/r RN, BSN,CCHP l(b)(6); (b)(?)(C) COR, USPHS ICE Health Service Corps Field Medical Coordinator - El Paso El Paso Field Office 11541 Montana Ave,l)�;)�\icl El Paso, TX 79936 915-856- (b)(B); Office (?)( 202-809- �! Mobile 866- 773- 7206 Secure Fax l(b)(6); (b)(?)(C) I Warning: nt is UNCLASSIFIED//FOR OFFICIAL USE ONLY {U//FOUO). It contains information e Freedom of Information Act (5 U.S.C. 552). It is to be that may be exempt from publtc r controlled, stored, handled, transmitted, distributed, an , cordance with DHS policy relating to FOUO information and is not to be released to the public or other personne ave a valid "need-to-know" without prior approval of an authorized DHS official. No portion of this report should be furnished to the media, either in written or verbal form. From: �(b)(6); (b)(?)(C) Sent: Thursday, December 13, 2018 11:16 AM To: l(b)(6); (b)(?)(C) · Subject: RE: OMI 2018-03102 Hernandez Rodriguez 0 • " I l(b)(6); (b)(?)(C) .._(l b.._.)(6....._)._ ; _.....,� is actively working on this case. At the moment, there is no ETA for completion. j(b)(6); (b)(?)(C) � I Unit Administrator Assistant to the Chief Medical Investigator New Mexico Office of the Medical Investigator MSC07 4040 l University of ew Mexico, Albuquerque, NM 87131 2020-ICLl-00006 1349 P: 505.925.J(b)(6)1t F: 505.925.0546 I https://omi.unm.edu/ From: ! Subject: Media Inquiry: death report on Roxsana Hernandez Hello, I am working on a story on the death report released on Roxsana Hernandez, which (along with others published recently) appears to be substantially shorter than those put forth by ICE historically. For death report in 2017 was 23 pages long. Hernandez's is just example, kb}(6}; (b}(7}(C} I 2. Given the amount of media scrutiny around her case, I am wondering about the brevity of her report and investigation surrounding her death. Also seeking answers on: -Why does the report not contain information about Hernandez's health from the point at which she was taken into CBP custody on May 9? -Why is her official autopsy not available? -Why was Hernandez's intake screening completed on May 17 when she came into ICE custody on May 9? -Does ICE intend to amend/ finalize this report further? I am asking because of the Congressional requirement to publish a report within 30 days and finalize after 60. I can be reached at 708-825-Kb}(�};__ I Thank you, l(b}(6}; 11 INTO (b}(6}; I Twitter b}(6}; } ( b}(7 (C} -t� ----------·1708.825. /h\/7\/ --- X 2020-ICLl-00006 1399 From: Sent: To: Subject: l(b}(6}; (b}(?}(C} 11 Dec 2018 21:20:06 +0000 !(b}(6); (b)(?}(C} ! RE: Please email it to me - Detainee Death Review - Jeffry HERNANDEZ No worries. I knew you were at NW. I aske i�\i�\rc) or email it to me. I opened it as a complaint involving both CBP (as the major culprit:)) and ICE. The information I requested from CBP is responded to in incomplete answers or are non-responses. In one email from one officer to another they said "CRCL is heavily leaning on us for this." In my opinion, they should not have transported her given what they knew about her health. She should have remained in the hospital in CA. I question the doctor who cleared her for travel too. CBP also should have noted her appearance, including her weight difference from her previous entry. It was a 40 lb loss! From: !/ b)/6): /b)(?)(Cl Sent: Tuesday, December 11, 2018 4:14 PM To:11h11R1· 1h11111r:1 p Subject: RE: Please email it to me - Detainee Death Review - Jeffry HERNANDEZ I'm at northwest for the l(b}(6}; Heath this week - I'll ask �\i�\�c} o send it to you. What did you say to CBP ... ? Sent with BlackBerry Work ( www.blackberry.com) From: J(b)/6): (b)(?)/C) Date: Tuesday, Dec 11 2018, 12:45 PM To: l(b}(6); (b}(?}(C} p Subject: Please email it to me - Detainee Death Review - Jeffry HER ANDEZ Will you please email it? I've been breathing heavily down CBP's neck on this one. Yesterday I officially made them sick of me, I think. Thank you. From:!/b)(6): (b)(?)(C) Sent: Tuesday, December 11, 2018 2:52 PM ....,= ,,.... ""',...,""".------------------------..... (b l ( 6l-: ( b l/7 l(Cl To: Asher, Nathalie R "4..,,. Davis, Mike P