EARM View Encounter Summary Page 1 of 2 EARM Logged In: __Person ID b)(?)(E Sex: M DOB: 01/03/1953 Current Age: 65 COB: IRAN COC: IRAN __________________ · Subjec 63 Processing Disposition: Warrant of Arrest/Notice to Appear RCA Look-Up -_______ ------- -----------Case b) (7)(E) Case Cate gory: [2A) Docket: DVS. D02 -GEO 14- 27 Special Class: Time in Custody: NIA Depart/ Cleared Status: ACTIVE Proceed With Removal: N/A Days Final Order in Effect: N/A (b)(5);(b)(7)(C) Current I Active Alerts I I J Detention History [ Criminal Samimi, Kamyar 022 732 918 Encounter Details 6 Encounter(s) linked to Person IDfb)(7)(E) I @ 0 0 0 0 - - I � - - - 7 - Subject Ref# ID A· Number Last Name 6 359887663 022732918 SAMIMI KAMYAR IRAN No Priority 01/03/1953 11/17/2017 359626359 022732918 SAMIMI KAMYAR IRAN No Priority 01/03/1953 10/14/2017 Unlink 353177985 022732918 SAMIMI KAMYAR 01/03/1953 06/27/2015 Unlink 5 359692427 3 356831512 4 2 022732918 SAMIMI 022732918 SAMIMI First Name KAMYAR KAMYAR coc Historical Priority IRAN No Priority IRAN No Priority IRAN No Priority loos Encountered on 01/03/1953 10/23/2017 Case (b)(7)(E) Case Category 12A - 01/03/1953 09122/2016 Unlink Unlink Unlink Page�of2 Encounter Details All information below may only be edited in EAGLE Event/ Incident Information Event Number:Kb )(7)( E) Event Occurred On: 11/17/2017 I Event Type: Fugitive Operations (Event) Subject Information Operation: N/A Primary Agent: [b)(6);(b)(7)( C ) Site: DEN Landmark: ADAMSC • ADAMS COUNTY Assigned On: 11/17/2017 Event Supervisor: � b)( 6);(b)(7)( C) Assigned On: 11/17/2017 FINS: 1238805650 Historical Priority: No Priority Role: P Control Name: SAMIMI Agg Felon: No Aggravated Felony Convictions Processing Disposition: Warrant of Arrest/Notice to Appear Middle Name: N/A Hair: BLK Nickname: NIA Complexion: MED A-Number: 022 732 918 First Name: KAMYAR Maiden: NIA Criminal Type: N/A Primary Citizenship: IRAN Race: W Transgender: N Date of Birth: 01/03/1953 SSN: N/A Age at Encounter: 64 Occupation: Auto Tech Weight: 150 Sex: M Marital Status: Single Juvenile Verified: N/A INS Status: Deportable POE: NEW YORK, NY Eyes: BRO Living?: Y Role Comment: NIA Entry Date: 04/1911976 Entry Class: Not Applicable Apprehension Date: 2017-11-17 09:00:00.0 Origin: N Site: DEN Age:65 Landmark: ADAMSC · ADAMS COUNTY Height: 68 Juvenile Status: N/A Arrest At/Near: Thornton, CO Accompanying Family Member Relation: N/A Accompanying Family Member Subject ID: N/A Speak/Understand English: Y Consequence Delivery System Selection: NIA Read/Write English: Y Primary Language: ENGLISH ..,,..f .,...,, ( ,,...,) = ____________....,,2'H0','i20'+=-++-IC~l-00006 b ) 7 (E) 001 2/14/2018 EARM View Encounter Summary 1-213 Narrative Page 2 of 2 Narrative 1 : Created Date: 11/17/2017 11 :58 AM PRIORITIES SUMMARY: -SAMIMI CLAIMS LAST ENTRY WAS AS AN F1 STUDENT ON OR ABOUT 04/19/1976. -SAMIMI HAS NEVER BEEN REMOVED. -SAMIMI HAS BEEN CONVICTED OF POSSESSION OF A CONTROLLED SUBSTANCE. -SAMIMI HAS NO GANG AFFILIATION. ENFORCEMENT b)(6);(b)(7)(C) ENCOUNTER DATA n investigation was started on the SAMIMI when SAMIMl's case was assigned to me by )SDDO fb)(6);(b)(7)(C) SAMIMI, Kamyar was encountered outside his home at 9001 Pozer Blvd, Thornton, CO 8022 on 11/17/2"t-'-'--. b)(6);(b)(7)(C) · · · etting into a silver KIA Optima with CO tag I, DO 1,,.,....._....::i---i.,---_____J A"P""":".JF.::"� approached the vehicle fully marked up as I o Icers. SAMIMI was :-:,-:.,--:.,--:,.,,...,i:-:-:"',-::1ewe 1 r:e�ntifying myself as an immigration officer. SAMIMI claims to be a citizen -:::-::--,o.-,fT. �a .:-.;.; v' " ir" - " y;.-::-e-::nt:.:e:-::rv r ..-: � ::, r: -:: � � n ::: -=i rt.. and national of Iran by vI ue o 1 • SAMIMI is a Lawful Permanent Resident (LPR) but did not have his LPR card on his person. He only had a copy. Subject was told that his conviction for possession of a controlled substance iolated his status and that he was under arrest by immigration for this violation. SAMIMI was then transferred to the Denver Field Office for processing. ENTRY DATA/IMMIGRATION HISTORY SAMIMI claims to have entered the United States at or near New York, NY, on or about 04/19/1976, as a F-1 student. his location is designated as a port of entry by the Attorney General or the Secretary of the Department of Homeland Security. SAMIMI claimed no other entries into the United States. ICE/CIS database checks indicate that SAMIMI adjusted his status to that of LPR IR-6, spouse of a US citizen, on 05/09/1979.applied for naturalization on 10/29/1985. On 01/09/1987, the application was denied due to lack of documents requested by the Immigration and Naturalization Service. FAMILY INFORMATION SAMIMI states that his mother was once a LPR but returned to IRAN and abandoned her status. He states that his father never received status. SAMIMI states that he is now divorced. SAMIMl's children are all adults and were born in the US. SAMIMI was, on 06/09/2005, convicted in the Arapahoe District Court, Centennial, CO for the offense of Possession of 1g/less of a Schedule 2 Controlled Substance, to wit: cocaine, in violation of C.R.S. 18-18-405(1),(2.3)(a)(I), a Class 6 Felony, and sentenced to a term of 2 years deferred sentence and 64 hours of community service.Case No. 2004CR1437 GANG AFFILIATION/PUBLIC SAFETY THREAT SAMIMI claims no gang membership. U.S. MILITARY HISTORY SAMIMI claims no military history. __________ b)(7)(E) __, for outstanding wants, warrants and lookouts were negative. DISPOSITION SAMIMI does not appear to meet the requirements for DACA due to his criminal history. SAMIMI was advised of the right to speak to a consulate officer from Iran. SAMIMI claims fear of persecution or torture if removed to Iran. SAMIMI has no immigration petitions or applications pending or approved. MEDICAL INFORMATION SAMIMI claims to be in good health. SAMIMI was given a detainee handbook in the English language. SAMIMI was iven a co of the ODLS rivac notice. United States Department of Homeland Security (OHS), U.S. Immigration and Customs Enforcement (ICE). Enforcement and Removal Operations (ERO) I Release EARM 5.45 2020-ICLl °0006 002 1 2/14/2018 Page 1 of 2 EARM Case Summary EARM )( ) __Person I b)(? E Logged In: ex: M DOB: 01/03/1953 Current Age: 65 COB: IRAN COC: IRAN _________________ _ Current I Active Alerts Subject ID : 359887663 Processing Disposition: Warrant of Arrest/Notice to Appear RCA Look-Up Case# !(b)( 7) ( E) !case Category: [2A) Docket: DVS • D02 • GEO 14-27 Final Order of Removal: No Time in Custody: N/A Depart / Cleared $talus: ACTIVE Final Order Dale: N/A Proceed Wilh Removal: N/A b)(5);(b)(?)(C) I Special Class: I J Detention History [ Criminal Days Final Order in Effect: N/A Samimi, Kamyar 022 732 918 Case Summary Important Case Oates Case Details Entry Date: 04/19/1976 Case Category: [2A] Deportable • Under Adjudication by IJ Apprehension Date: 11/17/2017 Final Order of Removal: No Case Creation Date: 11/17/2017 Final Order Date: N/A Charging Document 11/17/2017 Issued • 1862 : Are there reasons that prevent removal of the alien at this time? N/A Reason preventing removal: NIA Charging Document 11117/2017 Served - 1862 : Cleared-Depart Status: ACTIVE A-File to Trial Attorney: N/A Aggravated Felon: No Aggravated Felony Convictions Mandatory Detention: Yes Special Classes: Initial Book-in: 11/17/2017 (b)(6);(b) (7)(C) Last Book-in: 11117/2017 Final Book-out: 12/02/2017 Last Updated By: � ---� Last Custody Review: 11117/2017 Last Update: 11/21/2017 Travel Document N/A Requested: EOIR Search Case Closed: NIA Docket Assignment DCO: DVS • DENVER, CO, STAGE AREA SUB-OFFICE Docket Name: D02 • GEO 14-27 Case Call-ups IP Expires 12/08/2017 Status Completed Set Bv Description EOIR Termination l Hide Completed call-ups m hstmg 'b)(6);(b)(7)(C) I Set Date 11117/2017 Encounters Included in Case File i A-Number IP 022732918 Subject ID /h\!R\ /h\/7\/ I Last Name Samimi First Name IKamyar COB Age Entry Date IRAN 65 04/19/1976 Apprehended 11/17/2017 Disposition Warrant of Arrest/Notice to -�pear * Primary -- Administrative and Criminal Immigration Charges 2020-ICLl-00006 003 2/14/2018 Page 2 of 2 EARM Case Summary I I Charged Section 1111112011 8 USC 1227 1111112011 237a2Bi DACS Description DEPORTABLE ALIEN R2B1 DRUG CONVICTION Disposition -- Additional Charges of lnadmissibility/Deportability (1-261) Nothing found to display. Case Closure This case is currently Active. United States Department of Homeland Security (OHS), U.S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO) I Release EARM 5.45 2020-ICLl-00006 004 2/14/2018 Page 1 of 1 EARM Person History EARM Logged In (b)(?)(E ex: M DOB: 01/03/1953 Current Age: 65 COB: IRAN COC: IRAN----------------__Person ID: ­ Subject ID : 359887663 Processing Disposition: Warrant of Arrest/Notice to Appear RCA Look-Up (b)(7)(E) ase Category: 12A) Docket: DVS. D02. GEO 14-27 Final Or er o emoval: No Time in Custody: N/A Depart / Cleared $talus: ACTIVE Final Order Dale: N/A Proceed Wilh Removal: N/A (bl(5l;(bl(7 )(c) Current I Active Alerts I Case# Special Class: I J Detention History [ Criminal Days Final Order in Effect: N/A Samimi, Kamyar 022 732 918 Person History Encounter History Subject Ref# ID r Current Processing Diseosition 022 732 918 Last Name SAMIMI Historical COB Priority 022 732 918 SAMIMI IRAN NIA N/A 022 732 918 SAMIMI IRAN N/A N/A 022 732 918 SAMIMI IRAN N/A N/A Other 2 022 732 918 SAMIMI IRAN N/A N/A 1 022 732 918 SAMIMI IRAN N/A N/A Not Amenable to Removal (b}(7)(E) 6 5 - A-Number IRAN N/A Event ID Aeerehended (b)(7)(E) 11/17/2017 Case History Case # l(b)(7)(E) I Case Category pA • [2A] Deportable • Under Adjudication by IJ Detention History Initial Book In 11/17/2017 1548 11/17/2017 0935 Classification Level ML MH Historical Priority N/A LasUCurrent Detention Location DENICDF-DENVER CONTRACT DET. FAC. DENHOLD-DENVER HOLD ROOM DCO DVS l Not Amenable to Removal Other N/A Final Book Out Date 12/02/2017 1600 11/17/2017 1500 Unlink Case Unlink 1 Case Unlink I Case Unlink 1 Case Unlink Case Unlink I � � N/A Final Order of Removal ease # (b)(7)(E) Warrant of ArresVNotice to Appear � � � Unlink I I I Deeart-Cleared Status ACT Final Book Out Descrietion Released Transferred Alternatives to Detention (ATD) History Nothing found to display. Assessment HistoryPerson Assessment History jAssessment Date 1_11/17/2017 11:55 AM Encounter Assessment History Assessment Date 11/17/2017 11:52 AM Historical Priority Conditions NIA Has a criminal assessment Historical Priority NIA Assessed by EARM Conditions • Has a criminal assessment United States Department of Homeland Security (OHS), U.S. Immigration and Customs Enforcement (ICE), Enforcement and Removal Operations (ERO) I Release EARM 5.45 �b)(7)(E) 2020 ICLI ooros 005 2/14/2018 Audio File List # Inmate 01 Samimi, Kamyar Total: PIN (b)(6);(b)(7)( C) Call Time Duration Destination 11/19/17 18:13 05:00 05:00 Audio File List Station 720-937-7722 Med-Isolation 1 2020-ICLl-00006 006 ( A22732918 SAMIMI, KAMYAR DOB: 1/3/1953 �rrival Date: INTAKE SCREENING Nation: Sex: VD/R #: IRAN Facility Name: Aurora ICE Processing Center DOB: � Interpreter Name and/or#: 11/17/2017 16:00 in: suggesting need for emergency medical refernl? Is the � unconscious or have obvious pain, bleeding, inju ,J!!'No D Yes If yes, explain: Vcrt,ally D Arm band O Other (Explain): I/DIR was identified by (source): D 1D Card D Picrure IfVDIR was transferred from another facility, did a medical transfer summary accompany the I/DIR? � 0 Yes O NIA lfVD/R transferred from another facility, did !he 1/D/R arrive with medications? _Ja'1iio I. How do you feel today? (Explain in his/her own words): "'--:f \,u>.V'e.- uJ D Yes If yes, explain: · No 2. Have you fainted recently or have you ever had a head injury with Joss of consciousness? O Yes Ifyes, Cllplain: 3. Are you now or have you been treated by a doctor within the last 5 yrs for a medical condition, including hospitalizations? Jteessive sweating (fever) D Malnourished appearance D Developmental disabilities D Mobility restricted in any way D Skin: Bumps/rasMcsions/infcstations 0 Aids (hearing aids, glasses. dentures) Comments: Ifapplicable.,..liCC Result,. D Physical aids (cane, crutch, brace) D Shaking/tremors D Body defonnity D Olber S P Idit a 1ueahve ·5:::B:rfr:s-,d A: Initial Heahh Screening Completed: P: Disposition�eral Population ..a-'Tu D No O Refcnal for immediate medical, mental health, or dental care Education· �screcning explained LO I/DIR D Isolation until medically evaluated �cess 10 medical/dental/mental healthcare, grievance process explained 101/D/R � given medical orientation and health infor mation handouts in VD/R language was given written orientation matenals and/or translations m l/DIRs own language ft1ID/R _,....c--1fi literacy problem exists, screener assisted lbc l/D/R in undcrstllnding education handouts. A22732918 SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: Nation: �/R verbalized understanding of any teaching or instruction and was asked if hc or she had · · Care/lnterve · (b)(6);(b)(7)(C) Rcvic,.;nc Physician/NP/PA Paf!.e 2 of2 2020-ICLl-00006 008 HS-168 IRAN 11/17/20 17 16:00 OFFICE OF THE CORONER Adams & Broomfield Counties b)(6);(b )(?)(C) f CHIEF CORONER Name: SAMIMI, Kamyar Case Number: A17-3073 Age: 64 years Date of birth: January 3, 1953 Date and time pronounced deceased: December 2, 20 17; 1202 Hours Death Investigator: Brooke Steven b) (6);(b)(7)(C) Prosector: �---.....,,,..,.,.,,.,.. ..,,...,...,.==-,------, b }(6) ;(b) (7)(C) Autopsy Technician: �------� OPINION The cause and manner of death opinion is based on the scene investigation, examination findings, and history available at this time. Cause of Death: Undetermined Contributing Factors: Chronic Obstructive Pulmonary Disease (Emphysema) and Gastrointestinal Bleeding Manner of Death: Undetermined (b)(6);(b)(?)(C) 330 N.19TH AVE. BRIGHTON, CO 80601 P 303.659.1027 2020-ICLl-00006 009 F 303.659.4718 AUTOPSY REPORT NAME: ME#: KnMYnR snMIMI DATE AND TIME PRONOUNCED DEAD: DATE AND TIME OF AUTOPSY: AGE: 64 RACE: A17-03073 December 2, 2017 / 1202 Hours December 6, 2017 / 1000 Hours White GENDER: Male CIRCUMSTANCES OF DEATB This 64-year-old male was transporte d emcrgently to University of Colorado llospital on December 2, 2017. He was reportedly in the custody of ICE officers at the immigration detention center in Aurora at the time of his medical incident. He had been in the facility for two weeks prior to the incident and was under a direct supervision suicide watch when he was observed to be "spitting up blood". Apparently he had been suffering from gastrointestinal bleeding in the past. His social history included opium addiction at the age of six and addiction to methadone since 1990. He had been "clean" for two weeks in Lhe IC� facility and was being watched for withdrawal, dehydration, nausea and vomiting. IDENTIFICATION The decedent was identified by IC� officers. This was confirm ed by fingerprints. CIRCUMSTANCES OF POSTMORTEM EXAMINATION The autopsy was authorized b the Coroner of Adams County, and assisting were Colorado. Prosectin;...,....___;_;;......;;__.__ was (b)(B);(b)(?)(C) __________..L...:.e___;___;__;___;_, The autopsy technicians (b)(B);(b)(?)(C) autopsy was performed at the Adams County Coroner's Office. CLOTHING AND PERSONAL EFFECTS The decedent was clad in white socks and cutaway white boxer shorts. 2020-ICLl-00006 010 ME#: Al7-03073 KAMYAR SAMIMI EXTERNAL EXAMINATION The body was that of a thin, White male. An appropriate identification tag was on the lefl great toe and hospital identification tags were on the left ankle and left great toe. The body weighed 141 pounds, was 68 1/2-inches in height and appeared compatible with the reported aqe of 64 years. The Dody was cool. Full rigor mortls was present to an equal degree in all extremities. Mild, fixed, purple lividity was distributed over the posterior surfaces of lhe body, except in areas exposed to pressure. The scalp hair was receding, black with gray and 2 1/2-inches in length. Facial hair consisted of a black with gray beard and muslache. The irides were brown, the corneae were clear, the sclcrac were white, and the conjunctivae were pink/tan and free o[ pelechiae. Bloody black fluid flowed from the mouth and nose. The earlobes were not pierced. There were moderate transverse creases of the lower pinnae. The nasal skelelon was palpably intact. The lips were without evidence of injury. T'.1e lower teeth were in poor condition and the upper jaw was edentulous. Examination of the neck revealed no evidence of injury. Perimortem injuries to the chest will be described below. The abdomer. was flal and there was a possible 1-inch scar al the right anterior costal margin. The extremities showed no gross bony deformities or pitting edema. There was a 3/4-inch scar on Lhe right second finger and a 3/16-inch scabbed abrasion at the tip of the left second finger. The fingernails were inlacl. Tattoos were not noted. Needle tracks were not observed. The external genitalia were those of a circumcised adult male. The posterior torso was essentially without note. The anus was atraumatic. EVIDENCE OF THERAPY Evidence of medical intervention consisted of bilateral tibial i_ntraosseous lines; an endotracheal tube; two defibrillator pads on the chest; intravenous catheters in the right antecubital 2 2020-ICLl-00006 011 ME#: Al 7-03073 KAMYAR SAMIMI fossa and dorsal left hand; and venipuncture sites covered by dressings on the left forearm and in the left antccubital fossa. EVIDENCE OF INJURY A 1/4-inch abrasion was on the right side of the bridge of the nose. A 5/8-inch abrasion was on the lateral right zygomatic region. There were vaguely rectangular yellow abrasions overlying the sternum. Right ribs 3 - 7 and left ribs 2 - 6 were fractured anterolalerally. There was minimal associated internal bleedin g. INTERNAL EXAMINATION Body Cavities: The body was opened by the usual thoracoabdominal incision and the chest plate was removed. No adhesions or abnormal collections of fluid were present in any of the body cavities. All body organs were present in the normal anatomical positions. The subcutaneous fat layer of the abdominal wall was 1.2 cm thick. Head: (Central Nervous System) The scalp was reflected. The calvarium of the skull was removed. The dura mater and falx cerebri were intact. There was no subdural or epidural hemorrhage. The leptomeninges were thi.n and delicate. The cerebral hemispheres were symmctrical. The structures at the base of the brain, including the cranial nerves and blood vessels, were intact. Coronal sections through the cerebral hemispheres revealed no focal lesions. Transverse sections through the brainstem and cerebellum were unremarkable. The brain weighed 1,450 grams. The spinal cord was not examined. Neck: Examination of the soft tissues of the neck, including the strap ir.uscles and large vessels, revealed no abnormalities. The hyoid bone and larynx were intact. 3 2020-ICLl-00006 012 ME#: Al 7-03073 KAMYAR SAMIMI Cardiovascular System: The pericardia! surfaces were smooth, glistening, and unremarkable; the pericardia! sac was free of s.i.gnj ficant fluid or adhesions. The coronary arteries arose normally, followed the usual distribution, and were widely patent with no evidence of significant atherosclerosis or thrombosis. The cardiac valves were unremarkable. The chambers and valves exhibited the usual size-position relationships. The myocardium was red/brown and firm with no focal lesions; the atrial and ventricular septa were intact. The aorta and its major branches arose normally, followed the usual course, und were widely patent. The vena cavae and their major tributaries were returned to the heart in the usual di.stribution and were free of thrombi. 'l'he heart weighed 300 grams. Respiratory System: The upper airway was clear of debris and foreign material; the mucosal surfaces were smooth, yellow/tan and unremarkable. The pleural surfaces were smooth and gliste�ing with no focal lesions. The pulmonary parenchyma was purple/tan with diffuse emphysematous changes and bullae at the apiccs. The parenchyma exuded a mild amount of foamy fluid upon sectioning. 'rhere was marked anthracosis. No mass lesions were noted. The pulmonary arteries were normally developed, patent, and without thrombus or embolus. 'l"he right lung weighed 480 grc1ms; the left lung weighed 450 grams. Liver and Biliary System: The hepatic capsule was smooth, glistening and intact covering uniformly brown parenchyma. No mass lesio:.1s were noted. 'l'he gallbladder contained 4 mL of viscous, green/brown bile; the mucosa was velvety and unremarkable. The extrahepatic biliary tree was patent, without evidence of calculi. The liver weighed 1,500 grams. Alimentary System: The tongue exhibited no evidence of recent injury. The esophagus was lined by gray/wh.i.te, smooth mucosa. The gastric mucosa was slightly autolyzed and the lumer. contained 10 mL of bloody fluid. The small and Large bowels wec:-e unremarkable. 4 2020-ICLl-00006 013 KAMYAR SAMIMI ME#: Al7-03073 The ilium contained approxjmately 100 mL of partially digested blood and firm, black stool resided within the colon. No specific site of bleeding could be identified. The pancreas had a normal gray/white, lobulated appearance and Lhe ducts were clear. The appendix was present. Genitourinary system: The renal capsules were smooth and thin, semitransparent, and stripped with ease from the under.1ying smooth, red/brown cortical surfaces. 'l'he cortices were sharply delineated from the medulJary pyramids which were purple/tan and unremarkable. The calyces, pelves, and ureters were wiLhout note. The urinary bladder was empty; the mucosa was gray/tan and wrinkled. The right kidney weighed 110 grams; the left kidney weighed 130 grams. The prostate gland was unremarkable. Reticuloendothelial System: The spleon had a smooth, intact capsule covering red/purple, moderately firm par enchyma; the lymphoid follicles were unremarkable. The regional lymph nodes appeared normal. The spleen weighed 120 grams. Endocrine system: The thyroid and adrenal glands were unremarkable. Musculoskeletal System: Muscle development was normal. There was moderate degenerative joint disease of the thoracolumbar vertebral column. No nontraumatic bone or joint abnormalities were �oted. SPECIMENS/EVIDENCE OBTAINED Samples of peripheral blood, heart blood, cavity blood, gastric conlents, and vitreous fluid were obtained for toxico:ogy. A DNA card was retained for the file. Samples of the major organs were submitted for stock in formalir.. Two cassettes were submilled for histologic analysis. 5 2020-ICLl-00006 014 ME#: J\17-03073 KAMYAR SAMIMI MICROSCOPIC DESCRIPTION A - �eft lung: disrupted septae; atelectasis; anthracosis; edema; bacteria without inflammation; interstitial chronlc inflammation Liver: moderate stcatosis Left ventricle: unremarkable B - Right lung: disrupted septae; atelcctasis; anthracosi.s; edema; bacteria and intr abronchial gastric conlents without inf1ammation; interstitial chronic inflammation PATHOLOGIC DIAGNOSES I. Chronic obstructive pulmonary disease (emphysema) with marked anthracosis and Lerminal aspiration II. Lower gastrointestinal hemorrhage III. Thoracolumbar degenerative joint disease IV. CPR-related injuries V. Minor abrasions of face VI. Moderate hepatic steatosis VII. Toxicology (NMS Labs 17380380, peripheral blood): Negative VIII.Vitreous humor, chemistry studies: A. elevated glucose {183 mg/dL) B. Mild renal dysfunction 1. tlrea nitrogen = mg/dL 2. Creatinine = 1. 9 mg/dL C. No evidence of dehydration 6 2020-ICLl-00006 015 ME#: Al 7-03073 KAMYAR SAMlMJ OPINION This 6ti-year-old, White male, Kamyar Samimi, died of undetermined ca11ses. Chronic obstructive pulmonary disease (emphysema) and gastrointestinal bleeding likely contributed to death. Methadone withdrawal cannot be ruled o�t as the cause of death, however, deaths due to methadone withdrawal are rare. There were no injuries to explain death nor was there evidence of dehydration. (b)(6);(b)(7)(C) Forensic Pathology Consultant January 30, 2018 Date Dictated: 12/6/2017 Received for transcription: 12/6/2017 Transcribed: 12/6/2017 RES 7 2020-ICLl-00006 016 U.S. Department of Homeland Security Immigration and Customs Enforcement Office of Professional Responsibility Washington, DC 20536 External Reviews and Analysis Unit Detainee Death Review Kamyar SAM IM I Date of Death - December 2, 2017 Denver Contract Detention Facility Aurora, Colorado JI CMS Case · enforc Depar refere · mt-:m-ni-emlll.m ��c E b) (6);(b)(7)(C);( b)(7)( ) ent may contain s ·· · · oea,:�rre e of the 9!nt�ec!!� I deficiencies. In tlf:i...1�imld d�ltl'stlf9.,-'� or reproduction of , ohibited wit ifffli�f9Cl.o.i:.J2! · LAW ENFORCEMENT SENSITIVE 2020-ICLl-00006 017 Office of Professiona/ Responsibility U.S. Department of Homeland Security 950 L' Enfant Plaza SW Washington, DC 20536 U.S. Immigration and Customs Enforcement MEMORANDUM FOR: THROUGH: FROM: SUBJECT: Matthew Albence (b)(6);(b)(7)(C) Associate Director (b)(6);(b)(7)(C) (b)(6);(b)(7)(C) Assistant Directo Findings - Death of ICE detainee Kamyar SAMIMI (JICMS t���);(b)(7)(C) ;(b)(I The Office of Professional Responsibility,External Reviews and Analysis Unit (ERAU),has completed its investigation into the death of U.S. Immigration and Customs Enforcement (ICE) detainee Kamyar SAMIMI who died on December 2,2018,while in ICE custody, at the University of Colorado Medical Center (UCMC) in Aurora, Colorado (CO). The Adams & Bakersfield County Coroner's Autopsy Report docwnented SAMIMl's cause of death as undetermined but listed chronic obstructive pulmonary disease (emphysema) and gastrointestinal bleeding as contributing factors. On November 17,2017,ERO arrested SAMIMI at his residence in Denver, CO and served him with a Notice To Appear (NTA) charging him as removable under section 237(a)(2)(b) of the Immigration and Naturalization Act (INA) as an alien convicted of a controlled substance violation. ERO transferred SAMIMI to the Denver Contract Detention Facility (DCDF) 1 in Aurora,CO,that same day. During his intake screening on November 17,2017,SAMIMI reported taking between 150190mg of methadone daily and stated he was experiencing methadone withdrawal symptoms. Given SAMIMI's long-term use of high-dose methadone,nursing staffreceived orders from DCDF's physician to house the detainee in medical observation,complete laboratory work,take vital signs every eight hours,and give medications as needed for anxiety,restlessness, sleeplessness, nausea,and pain. The physician did not order monitoring of SAMIMI's withdrawal symptoms using any standardized instrument.2 1 The facility is also referred to as the Aurora County Processing Center, but "DCDF" is used throughout this memorandum and the Detainee Death Review report for consistency. 2 The Clinical Opiate Withdrawal Scale (COWS) is a widely-recognized and used instrument for monitoring opiate withdrawal. GEO also has a limited monitoring instrument entitled, "Alcohol/Drug Withdrawal Monitoring Sheet." 2020-ICLl-00006 018 SAMIMI remained in the medical unit for the duration of his 16 days in detention, and his laboratory test results were within normal limits, with the exception of an abnormally high thyroid hormone and a slightly low hemoglobin level. In contravention of physician's orders, nurses took vital signs only twice daily, on average (rather than every eight hours). Although SAMIMI's observed condition indicated a need for withdrawal medications, nurses administered less than half of the doses ordered. DCDF's physician never physically examined the detainee. Mental health professionals saw SAMIMI on three occasions. A staff psychologist conducted the initial evaluation in-person on November 20, 2017, and psychiatrists conducted the second and third evaluations via tele-psychiatry on November 29, and November 30, 2017, respectively. During the second evaluation, following his attempted suicide, the psychiatrist directed that SAMIMl's suicide watch level be lowered, prescribed medication changes, and ordered monitoring of his withdrawal symptoms using COWS. Medical staff never completed any COWS. During his final mental health encounter, two days before his death, SAMIMI stated he was stressed, depressed, and wanted to die due to his symptoms of methadone withdrawal. The psychiatrist continued SAMIMI on suicide watch and his medications. All officers interviewed observed significant deterioration in SAMIMl's condition, especially during the 48 hours prior to his death, and expressed concern about the care provided by nursing staff during interviews. Nursing notes prepared during SAMIMl's detention, corroborated by video surveillance footage, reflect a progressive deterioration in SAMIMI' s health, starting on November 22, 2017. They include the following observations regarding his condition: tremors, pain and weakness, nausea and vomiting, refusing meals, inability to sit up in bed or in a wheelchair, incontinence and signs of dehydration. The majority of nurses interviewed stated they believed SAMIMI was malingering and seeking drugs throughout his stay and did not see an urgent need to notify the physician of his worsening condition. SAMIMl's condition started to rapidly deteriorate the night of December 1, 2017, when he appeared to spit up blood, complained of stomach pains throughout the night, and vomited frequently. The morning of December 2, 2017, while two officers and a nurse attempted to move SAMIMI into a wheelchair, he exhibited symptoms of seizure. The officers returned him to his mattress where they observed him vomit and urinate on himself. Over the following approximately six minutes, an RN made several unsuccessful attempts to contact the physician for guidance on managing SAMIMI. Meanwhile, the officers contacted their Lieutenant, who directed that 911 be called immediately. Emergency Medical Services (EMS) arrived on the scene approximately four minutes later. SAMIMI stopped breathing shortly after their arrival, and paramedics performed CPR during the detainee's transit to the Emergency Room (ER). ER staff were unable to resuscitate SAMIMI, and an ER physician pronounced his death at 12:02 p.m. ERAU reviewed DCDF's compliance with the ICE PBNDS 2011 (revised 2016) as they relate to SAMIMI's medical care, safety and security, and found DCDF did not fully comply with the standards detailed below. These deficiencies are noted for informational purposes only, and should not be construed as contributory to the detainee's death. 2 2020-ICLl-00006 019 1. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(B), states "All facilities shall provide medical staff and sufficient support personnel to meet these standards." At the time of SAMIMI's detention, DCDF had vacancies in key medical personnel, including a Director of Nursing and a midlevel provider, for longer than six months. 2. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(G)(12), states, "Each detention facility shall have and comply with written policy and procedures for the management of pharmaceuticals ... to include: (12) documentation of accountability for administering or distributing medication in a timely manner, and according to licenses provider orders." In spite of SAMIMI's frequent and progressive complaints related to symptoms of withdrawal, nurses administered less than 50% of physician-ordered withdrawal medications to be given on an as needed basis. 3. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(J), states, "Where there is a clinically significant finding as a result of the initial screening, an immediate referral shall be initiated and the detainee shall receive a health assessment no later than two working days from the initial screening..." The intake nurse's documentation of SAMIMI's possible early opioid withdrawal did not result in an initial provider assessment within two working days of intake. 4. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(K), states, "Detainees experiencing severe or life-threatening intoxication or withdrawal shall be transferred immediately to an emergency department for evaluation. Once evaluated, the detainee will be referred to an appropriate facility qualified to provide treatment and monitoring for withdrawal, or treated on-site if the facility is staffed with qualified personnel and equipment to provide appropriate care." DCDF medical staff failed to transfer SAMIMI to an ER even though he exhibited life threatening withdrawal symptoms in the week following his intake. 5. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(M), states, "Each facility's health care provider shall conduct a comprehensive health assessment, including a physical examination and mental health screening, on each detainee within 14 days of the detainee' s arrival unless more immediate attention is required due to an acute or identifiable chronic condition." DCDF failed to complete an initial physical assessment during the 15 days SAMIMI was housed at the facility, in part due to the absence of a midlevel provider. 6. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(N), states, "Where a detainee has a serious medical or mental health condition or otherwise requires special or close medical care, medical staff shall complete a Medical/Psychiatric Alert form (IHSC834) or equivalent, and file the form in the detainee's medical record." Medical staff did not complete a Medical/Psychiatric alert for SAMIMI. 7. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(R), states, "An initial dental screening shall be performed within 14 days of the detainee's arrival. The initial · dental screening may be performed by a dentist or a properly trained qualified health 3 2020-ICLl-00006 020 provider." Medical staff did not schedule SAMIMI for a dental screening examination. 8. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(T), states, "An on-call physician, dentist, and mental health professional or designee, are available 24 hours per day." Nurses reported difficulty reaching Dr. Peterson outside of his work hours. On the day of SAMIMI's death, the physician did not answer or return two phone calls. 9. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(U), which states, "Distribution of medication (including over the counter) shall be performed in accordance with specific instructions and procedures established by the HSA, in consultation with the CMA. Written records of all prescribed medication given to or refused by detainees shall be maintained." Nurses failed to document administration of SAMIMI's medications on numerous occasions. 10. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(X), which states, "The facility administration and clinical medical authority shall ensure that the Field Office Director is notified as soon as practicable of any detainee housed at the facility who is determined to have a serious physical or mental illness or to be pregnant, or have medical complications related to advanced age, but no later than 72 hours after such determination. The written notification shall become part of the detainee's health record file." DCDF did not notify the Field Office Director that SAMIMI was withdrawing from methadone and that his condition deteriorated during the detention period. 11. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(AA), which states, "Prior to the administration of psychotropic medication, a separate documented informed consent, that includes a description of the medication's side effects." An informed consent specific to the anti-depressant/sedative Trazodone was not completed and signed by the detainee. 12. ICE PBNDS 2011 (revised 2016), Significant SelfHarm and Suicide Prevention and Intervention, Section (V)(F), which states, "All suicidal detainees placed in an isolated confinement setting will receive continuous one-to-one monitoring, welfare checks at least every 8 hours conducted by clinical staff, and daily mental health treatment by a qualified clinician." Nursing staff did not conduct a welfare check on SAMIMI during the 14 hours between his placement on suicide watch and his evaluation via tele­ psychiatry. In addition to these findings of non-compliance, ERAU identified several areas of concern which are discussed in the attached report. If ou have an questions, lease contact me or have a member of your staff contact Unit Chief, at (202 (b)(6);(b)(7)(C) (b)(6);(b)(7)(C) Attachment cc: Peter T. Edge 4 2020-ICLl-00006 021 5 022 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS blC5l;(blC7lcc ) notified her of his reported withdrawal. Wherfbl(5);(b)(7)(C) lspoke with SAMIMI, he stated that he took 190 mg of methadone on a daily basis for detoxification from other drugs. 16 SAMIMI signed a consent for medical, dental, and mental health services 17 and an authorization for DCDF to obtain his health info1mation. 18 A screening chest x-ray completed during SAMIMI's intake screening showed no acute cardiopulmonary disease or evidence of active tuberculosis. 19 =!.....,I (b (6) (b)(7)(C) After evaluating SAMIMI, l(b)(6);(b} (7)(C) I to report the detainee's I called l ) ; methadone use and documented receipt of the following telephone orders frorrfbl(5);(b)(7)(C ) 120 1. Stat 21 laboratory studies to include a complete blood count, 22 com rehensive metabolic panel, 23 thyroid stimulating hormone, 24 and formal urine. 25 b)( 5 );(b)(7)(C) drew the blood samples and sent them for laboratory testing. 26 2. Medications for withdrawal, to include: 27 13/d. ERAU Interview with HS ) dated December 09, 2017. (b ERAU Interview with LP 7) (b)(6);(b)(7)( December 09, 2017. 16 dated December 09, 2017. ERAU Interview with RN RC) 11 See GEO Consent to Medical, Dental, Mental Health Services and Medical Interpretation, dated November 17, 2017. 18 See GEO Authorization to Disclose/Obtain Protected Health Information, dated November 17, 2017. 19 See Pacific Mobile Radiology Report, dated November 18, 2017. 21(b}(6 ;(b)(7 )(C) �id not document whether the orders were read back to verify accuracy, ancfb)(6);(b )(7)(C) �id ) not sign to authenticate his verbal orders. The Colorado Revised Statutes Title 25 Health § 25-3-11 I requires verbal order authentication within 48 hours, unless a read-back and verify process is in place, in which case the authentication must occur within 30 days. 21 Stat means immediate. See Exhibit 1. 22 A complete blood count is a test that provides information about the various cell concentration in a patient's blood to assist in disease diagnosis. See Exhibit 1. 23 A comprehensive metabolic panel is a test that provides information about the status of your metabolism, including kidney and liver function, electrolyte balance, blood glucose, and blood proteins, in order to monitor such conditions as hypertension and diabetes. See Exhibit I. 24 A thyroid stimulating hormone (TSH) test is a blood test that measures the level of this hormone to determine if the thyroid gland is functioning properly. See Exhibit 1. 25 A formal urine, or urinal sis, is a test that analyzes the culture and contents of a urine sam le. See Exhibit I. 26 ERAU Interview with b)(6);(b (7)(C) she drew ated December 09, 2017. According to b)(6);(b)(7)(C) ) blood samples and sent them to the laboratory that same night; however, the laboratory report documents their receipt date as November 20, 2017. 27 !(b (6) (b )(7)(C !ordered all withdrawal medications on an as needed basis. Per Creative Corrections, standard ) ) ; nursing practice calls for assessment of patient symptoms prior to administration of as needed medications, and documentation of the justification for administration in a nursing note and recordation of the administration in both a 14 15 3 2020-ICLl-00006 025 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS # • • rt5>;<7>;<7>< Ativan 28 1 mg intramuscularly up to three times daily as needed for 15 days. 29 Clonidine 30 0.1 mg orally up to three times daily as needed for 15 days. Note: As noted by Creative Corrections, GEO Clinical Practice Guidelines (CPG) for opiate withdrawal calls for giving clonidine in doses of 0.1 to 0.2 mg orally three to four times daily, as a means of controlling hypertension and somnolence, 31 and suggests interval dosing at specific times rather than on an as needed basis. AlthoughKb)(6);(b)(?)(C) !ordered administration as needed, the Medication Administration Records (MAR) for both clonidine and Ativan set 9:00 a.m., 3:00 p.m., and 9:00 p.m., as the times for administration. The MAR entries for all of SAMIMI' s ordered medications were inconsistent throughout the detention period, with times not recorded at all or noted at times which did not align with nursing notes. Regarding the irregular MAR entriesJ<5>;(b)<7>;(b)<7> I DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS � 3. Hold (house) in medical. 4. Appointments with psychology and physician. • SAMIMI was seen by the psychologist on November 20, 2017, 36 described !Provider Appointment below, but nursing staff never added him torb)( 5);(b)(?)(C) Log, despite the doctor's order and the clinically-significant findings identified during the intake screening. 37 5. Increase and encourage fluids. 6. Vital signs every eight hours until further notice. 38 • 5 Althoughfbl( );(b)(?)(C) I created a MAR for SAMIMI's vital signs which specified they be taken every eight hours, nurses did not make any notations on the vital signs MAR throughout his detention. Nurses only documented vital signs in their notes, and on three occasions (November 25, November 30, and December 1, 2017) documented blood pressure readings on a separate Blood Pressure Record. Further, nursing notes show SAMIMI's vital signs were taken only once or twice per day rather than every eight hours. Health Services Administrator (HSA) Vineyard stated nurses mistakenly understood that vital signs were to be conducted once per shift, and because many worked 12 hour shifts, vital signs were not taken every eight hours as ordered. 39 Additionally, SAMIMI was not weighed again following intake, and his pulse oxygen saturation was not consistently taken with vital signs. �b)(5);(b)(?)(C) !stated pulse oxygen saturation and body weight should typically be taken when obtaining vital signs.40 (b)(5);(b)(?)(C) stated that his orders were based on GEO' s CPG for opioid withdrawal. 41 Dr. (b)(6);(b)(7)(C tated he opted not to order an EKG as recommended in the CPG because he thought it more important to have the laboratory tests done. i;<7>;<7>< Commission on Conectional Health Care (NCCHC) 42 mandates monitoring using validated instruments. 43 At approximately 10:30 p.m.Jb)(6);(b)(7)(C) I conducted a nursing round during which SAMIMI stated he felt terrible. SAMIMI' s vital signs were within normal limits with the exception of a slightly elevated blood pressure of 130/94. He denied chest and abdominal pain but complained of generalized level eight pain. 44 j(b)(5);( b)( ?)(C ) lnoted SAMIMI reported nausea and vomiting two hours earlier and described his emesis45 as "hardly anything" and "greenish" in color. He reported he had a "watery" bowel movement on November 20, 2017. 46 lnoted tremors in his hands and an unsteady gait. Her nursing plan included l<5>;(b)(?)(C);(b)(?)(E) I DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS � On November 22, 2017, SAMIMI accepted all three meals but declined recreation and a shower. 70 At 6:00 p.m., SAMIMI spoke witt-J (b)(6);(b)(7)(C) I who documented SAMIMI complained of nausea and vomiting, generalized pain, tremors, and shivering related to methadone withdrawal. SAMIMI' s vital signs were all within normal limits. SAMIMI reported his last caloric intake was at 5:00 .m. at which time he ate 50 percent of his dinner, and he complained of nausea after eating. (b)(5);(b)(7)(C) nursing plan included continued monitoring, administration of medications, and increasing fluids as tolerated. 71 On November 23, 2017 SAMIMI accepted all three meals but declined recreation and a shower. 72 At 11: 15 a.m.fbl(5);(b)(7)(C) I observed that SAMIMI was alert and oriented, with mild hand tremors and level four generalized pain. SAMIMI' s vital signs were all within normal limits. b)(5);(b)(?)(C) encouraged SAMIMI to increase his fluid intake. 73 At 1 :30 p.m.jb)(6);(b)(l)(C) I spoke with SAMIMI, who complained of pain and weakness and spent most of the shift in bed. His vital signs were all within normal limits with the exception of a mildly elevated blood pressure of 134/93. 74 On November 24, 2017, SAMIMI did not accept any of his three meals and declined recreation and a shower. The medical officer noted that SAMIMI did not eat breakfast due to abdominal pain and that he notified a nurse. 75 During the early morning hours (4: 11 a.m. to 7:45 a.m.), the medical officer logged that SAMIMI had difficulty sleeping, asked for ice chips, and cried out for a nurse several times due to abdominal pain. The officer logged notifying a nurse of SAMIMI' s complaints and receiving permission to give the detainee ice chips. The officer logged that a nurse did not assess SAMIMI until 11: 15 a.m., at which time the nurse administered medications and approved more ice chips. The medical record contains no entries addressing these events. At 1 :45 p.m�(b)(6);(b)(7)(C) !conducted a security round. SAMIMI approached his cell door and told her he was having abdominal pain. She told him she would notif nursino- staff, but before she left to get a nurse, SAMIMI fell to the floor of his cell. b)(5);(b)(?)(C) called for nursing assistance, 76 andl(b)(5);(b)(?)(C) land other responders arrived. 77 l(b)(5);(b)(7)(C) lstated that when he arrived, SAMIMI was unresponsive and lying on his back on the floor. l(b)(6);(b)(7)(C)lapplied a sternal rub, and SAMIMI began to regain consciousness. (b)(5);(b)(7)(C) stated he assisted SAMIMI into a seated position, at which time the detainee made eye contact and stated he had not eaten in four days. He then lost consciousness a second time. i<5>;(b)(l)(C);(b)(l)(E) DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS � I elevated temperature of 98.8 si nifying a slight fever. SAMIMI stated his last bowel movement was the revious day. (b)(6);(b)(l)(C) noted SAMIMI's dinner intake at 5:00 p.m. was 50 percent. (b)(5);(b)(l)(C) noted SAMIMI had signs and symptoms of withdrawal, but no tremors or seizures. �b)(6);(b)(7)(C) I nursing plan was to continue monitoring the detainee and encourage food and nutritional intake. 81 On November 25, 2017, SAMIMI refused all three meals and declined both recreation and a shower. 82 At an undocumented time,fb)(5);(b)(7)(C) �poke with SAMIMI, and he complained of abdominal pain at a level six, with weakness, nausea, and vomiting. SAMIMI's vital signs were all within normal limits, with the exception of a mildly-elevated blood pressure. SAMIMI's heart, lungs, and abdomen were normal, and he reported having his last bowel movement the previous day. 83fb)(6); (b)(7)(C) ldid not document whether he gave the detainee any medications. 5 7 hated that SAMIMI was lying in bed and stated he did not sleep At 6:30 p.mJC5);(b)(?)(C) I nursing assessment included dehydration, and the detainee's nutritional needs not bein met. The nursing plan was to continue to monitor and administer medications as ordered. (b)(5);(b)(?)(C) ducated SAMIMI on the need to make an effort to eat and drink. l(b)(6);(b)(?)(C) lalso wrote, "no matter his actions, stronger meds unavailable." 101 ICb)(5 );(b)(?)(C) !explained that he included this notation to make the point to SAMIMI that he was not helping himself by his actions (refusing meals and purposefully falling) and that he needed to cooperate because he was not going to get methadone. 102 I After SAMIMI' s fal1J(b)(5);(b)(7)(C) discussed SAMIMI's state withl(b)(5);(b)(?)(C) land they agreed that SAMIMI was not stable enou h to roceed with his mental health follow-up appointment that day. fbl(6);(b)(?)(C) pssured b)(5);(b)(7)(C) that medical was monitoring SAMIMI' s vital signs and that SAMIMI had experienced a few good days and that his laboratory results looked good. ICb)(6);(b)(7)(C) �tated SAMIMI would remain in medical observation as he underwent withdrawal, and when he stabilized enough to have a coherent conversation, he would return to the mental health clinic. 103 Suicide Attempt At approximately 8:45 p.m.J(b)(5);(b)(?)(C) I the medical officer on duty, entered the anteroom of SAMIMI's cell to perform a security round. When she looked through the window, I reached for she observed SAMIMI with a dark blue sheet tied around his neck. 104 Kb)(6);(b)(7)(C) the radio on her duty belt so she could call an emergency. Discovering the radio was dead, she hunied to the officer's station and used the telephone to call central control for assistance. She returned to the cell, alerting nursing staff along the way that there was an emergency. Officer \�/\�/bl opened the cell door, and the responding medical and security staff removed the sheet from around the SAMIMI' s neck, despite some resistance from him in the process. Officer l(b)(6);(b)( 5tated she heard someone say SAMIMI would be placed on suicide watch, so she left to make preparations. Her preparations included setting up the officer's table and constant watch logbook outside the suicide prevention cell, and retrieving a suicide resistant smock and blanket confirmed thadCb)(5);(b)(?)(C) lplaced SAMIMI for issuance to the detainee. 10:i fbl(6);(b)( ?)(C) on constant suicide watch which was "started immediately." 106 I DCDF CCTV footage documents the following sequence of events: • • At 8:44:58 p.m., SAMIMI, who was sitting cross legged on his bed, took a blue sheet from his bed and placed it around his neck from behind. He then crossed each end over the other and tightened the sheet by pulling with each arm. !entered the camera's view at the end of the hallway and At 8:46: 16 p.m.Jbl(5);(b)(7)(C) entered the outer door into the anteroom outside SAMIMI' s cell. See GEO Medical Prooress Note b/b)(5);(b)(?)(C) lated November 28, 2017. ERAU Interview with[b)(6);(b)(7)( l:lated December 09, 2017. 103 See GEO Medical Progress Note by!( )(6);( )(7)( ) kiated November 28, 2017. b b C •04 See GEO General Incident Re ort b (b)(6);(b)(7)(C) dated November 28, 2017. 105 ERAU Interview wit b)(6);(b)(7)(C) dated December 11, 2017. ..,..,=....,,...,..,=..,.,,.,...--, 106 See GEO General Incident Report (Supervisor's Notes) b�"" (b)(6);(b)(7)(C) 1:lated November 28, 2017. 101 102 14 2020-ICLl-00006 036 H7> E> l<5> DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS (b ;(b)(?)(C);(b < • • • • • • • • • • • • At 8:46:33 p.m_fb)( 6);(b)(?)(C) lexited the outer door into the corridor and walked to the nurses' station approximately ten feet away. She motioned to the nurse to come to the door. The nurse opened the door at 8:46:54 p.m. At 8:47:25 p.m.Jb)(6);(b)(?)(C) Mialked back to the officer's station, approximately 10 feet from the nurses' station, holding her radio in her left hand. She looked at the monitor on her desk displaying camera views of the cells and picked up the phone. I hung up the phone, returned to SAMIMI's cell and At 8:48:14 p.m.Jbl(6);(b)(?)(C) opened the outer door at 8:48:32. At 8:49: 12 p.m., b)(6);(b)(?)(C) and an unidentified officer entered the cell. fbl(5);(b)(?)(C) (b)( 6);(b)(7)(C) entered behind them. tb)(6);(b)(7)(C) I and the first officer removed the sheet from around SAMIMI's neck as he struggled briefly and tried to push them away. Several more officers mTived. SAMIMI spoke with the staff as his property and linens were removed from the cell. He was seated on the bed, cross-legged and leaned forward with his hands on his forehead. At 8:51:18 p.m.. tbl(6);(b)(?)(C) I picked up SAMIMI' s Styrofoam meal container, which appeared to contain a full meal, and looked inside. At 8:51:25 p.m., an officer removed SAMIMI's property bin from the room, and RN K�!\?_);(b)( lopened the meal container and showed it to the detainee. At 8:51:41 p.m., SAMIMI shook his head no, andl(b)(6);(b)(?)(C) lset the container on the floor at the end of the bed. i<5>:<7>;<7> Security staff placed SAMIMI on level 1 suicide watch with constant, one-on-one monitoring. Medical and securit staff took SAMIMI to cell 527 which is the desi nated suicide watch cell (b)(7)(E) The door has a window in the top half and a pipe sensor in the middle. To the right of :::-::ir::: '---n::-e o�or is a large viewing window. Bolted to the center of the floor inside the cell is a concrete A stainless steel toilet nd sink combination fixmre is in theback left corner ofthe �::i_,!J1ll,E, : I l(b)(7)(E) ] The desk for the officer assigned to constant watch was positioned immediately outside the large viewing windo�(b)(?)(E) I The officer was required to log the activity of the detainee every five minutes in the Constant Watch Logbook (separate from the Medical Unit Logbook) and not allowed to leave the post without being properly relieved. Per the ICE PBNDS 201 l(revised 2016), detainees placed on suicide watch are to receive eight­ hour checks by clinical staff and daily mental health treatment by a qualified clinician. However, there were no medical record entries documenting any encounters with a health care professional between the time SAMIMI was placed on suicide watch and 11:00 a.m. the next morning. Nurse/clinician welfare checks were not conducted every eight hours as required by the ICE PBNDS. On November 29, 2017, an officer notated SAMIMI accepted his breakfast tray but did not make notations regarding lunch or dinner, or whether he refused or accepted a shower or recreation. At 10:58 a.m., ERO Deportation (b)(5);(b)(?)(C) entered the Medical Unit to conduct staff-detainee communication. 110 At 11 :00 a.m. b)(6);(b)(?)(C) I completed an initial psychiatric evaluation with SAMIMI via tele-psychiatry. !(b)( 6);(b)(7)(C) documented that SAMIMI complained of inability to sleep, constant vomiting, sweating, and shaking. He denied other opiate symptoms of yawning, tears, and dianhea. He also denied suicidal intent. .________---;:::===�-- !observed that SAMIMI's CIWA score consistently increased over time and noted l(b)(6);(b)(?)(C) that medical staff reported SAMIMI had tremors and frequently requested stronger medication. llisted what to expect with opiate withdrawal, including a notation that it is l(b)(6 );(b)(?)(C) generally not life-threatening, although dehydration is possible. She also addressed the unsuitability of using the CIWA instead of an opiate withdrawal instrument. Her findings included 01ientation to person, place, time, and situation; appropriateness of rapport; disheveled appearance with poor grooming, dress, and body odor; 111 anxious, irritable mood; expansive affect; and coherent, appropriate speech. 112 l(b)(5 );(b)(?)(C) �iscussed symptoms and treatment of mental illness, the frequency of follow-up, prescribed medications and potential side effects, and explained SAMIMI's access to mental 109 110 111 112 ERAU Interview withfb)(6);(b)(?)(C) !dated December 11, 2017. See GEO Medical Housing Unit Log, dated November 29, 2017. kb)(6);(b)(7)(C ) !description of the detainee's bod odor was likely reported to her b�(b)(6);(b)(?)(C) dated November 29, 2017. See GEO Initial Psychiatric Evaluation b) b)(6);(b)(?)(C) 16 2020-ICLl-00006 038 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS (b)(6);(b)(7)(C);(b)(7)( E) health services. She also documented medication consent forms were reviewed and signed. 1 1 3 l(b)(6);(b)(7)(C) !entered nine orders: 114 1. Push fluids for 15 days; 2. Discontinue Ativan; 3. Clonidine 0.1 mg orally three times daily for four days, then clonidine 0.1 mg twice daily for four days, then 0.1 mg every night for four days, then stop; 4. Hydroxyzine 115 50 mg three times daily as needed for anxiety for 15 days. 5. lmodium1 16 2 mg after each loose stool, total daily dose not to exceed 16 mg as needed for three days; 6. Trazodone1I7 100 mg orally every night as needed for sleep for 15 days, then decrease to 50 mg every night for 15 days, then stop; 7. Offer Ensure with each meal for seven days; 8. COWS monitoring for ten days; 1 18 9. Level 2 suicide watch. b (5);(b)(7)(C) i<5>;<7>;<7> DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS �L iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii ____Jliiiii l After instructing the Central Control Officer to call 911, Lieutenant )�i ; (b )(? ) returned to SAMIMI's cell and told SAMIMI that an ambulance was on the way. Lieutenanl( b)(6);(b )(7)(1 stated he observed vomit on and near SAMIMI's face and a substance that looked like blood on the (b)(6);( b )(?)(C) floor. The Lieutenant then went to the armory to issue weapons to Of · 6);( b)(?)( �/< whom he assigned to accompany SAMIMI to the hospital. Lieutenan also assigned perimeter patrol Officer �( b)( 6);(b )(?)(C) �o report to the perimeter gate to escort the paramedics into the facility. At 11: 16 a.m., the Aurora Fire Department (AFD) dispatched a team consisting of two Emergency Medical Technician (EMT,L,--L at the facility at 11:18 a.m. 160 Officer )�i ;(b)(?) opened the perimeter gates for the EMS responders and escorted them through the intake area and into medical. 161 GEO Medical Progre�=4'Y RN( b) (6);(b)(ldated December 2, 2017. (b)(5);( b ated December 11, 2017. ERAU Interview with 156 ERAU Interview with ( b)(5);(b)( ?)(C dated December 10, 2017. 157 GEO CCTV footage shows Lieutenaq ( b)( 6);(b )( 7)( �nd Office� (b)- ( 6- );(�b arriving on scene and looking in the cell at 7 C -11 :07 a.m. � � 158 7 6 RN l��1�7Hb �ocumented that he then called HSA (b)( );(b)( ) ho ordered that 911 be called. RN stated that after speaking with HSA (b)( 6);(b)( 7)( e went back to the ce area and found LieutenanK���);( b)( was there. He told the lieutenant that he re rder for SAMIMI to go to the hospital, whereupon the lieutenant asked if the detainee could "support his own weight." When told he could not, the lieutenant called 911 for him. RN�kb )-( 6-),( b) (�71 6);(b )(7)( and not supported account of events leading to calling for an ambulance is inconsistent with Lieutenant b )(-._...,_\ --' by any other evidence, written or reported. 159 ERAU Interview with Lieutenantl( b) (6);(b)( dated December 09, 2017. 160 See Aurora Fire Department EMS Patient Care Report, dated December 2, 2017. 161 ERAU Interview with Officerl(b)(6);(b)( 7 dated December 09, 2017. 154 See 155 I I I 23 2020-ICLl-00006 045 7)(E) 7 5 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JI CMS j(b)( );(b)( )(C);(b)( According to the AFD report, the EMTs found SAMThtll "lying prone in the holding cell with emesis on the mattress." He was unresponsive and pulseless with no obvious signs of trauma. The EMTs gave SAMIMI cardiopulmonary resuscitation (CPR) and put a Basic Life Support airway 162 in place. SAMIMI had "coffee ground type emesis" in his airway, and the EMTs continuously suctioned to clear the airway. The EMTs administered epinephrine and continued CPR, which was momentarily delayed when they moved SAMThtll from the floor onto a gurney and out to the ambulance. 163 The EMTs reported SAMThtll had agonal 164 respirations at a rate of two per minute, and their monitor showed him to be in asystole. 165 They gave SAMThtll a total of nine rounds of CPR, and he remained in asystole until the eighth round, when he transitioned to ventricular fibrillation, 166 The EMTs shocked SAMThtll once, but at the next heart rhythm check, he was back in asystole. 167 l(b)(5);(b)(?)(C) !escorted the EMS responders to the ambulance, and the ambulance left the facility at 11:40 a.m. for the emergency room at the University of Colorado Health Medical Center (UCMC). 168 fb)(5);(b)( ?)(C) I rode in the ambulance in the front passenger seat and Officer 5) (b)(7 ; l followed in a chase vehicle. The ambulance arrived at the University of Colorado e 1cal Center at 11:45 a.m. 169 Upon arrival at the UCMC Emergency Room (ER), SAMThtll had fixed pupils and was in asystole. The ER physician's preliminary diagnosis was cardiac arrest. ER personnel noted SAMThtll had black vomit on his face and in his airway suggestive of a possible gastro-intestinal bleed. 170 i�i At 12:02 p.m., SAMThtll was pronounced dead by UCMC physicia (b)C5l;(b)(?)(C) b)(6);(b)(?)(C) p.m., hospital staff moved SAMThtll's body to the morgue, and ...._ to the facility. 172 At 2:32 __,returned ________ 171 Post-Death Events On December 6, 2017, at approximately 10:00 p.m., an autopsy was performed on SAMThtll by ICb)(5);(b)(7)(C) lof the Adams & Broomfield County Coroner's Office.�b)(5);(b)(?)(Ckecorded SAMThtll's cause of death as undetermined, but documented SAMThtll had chronic obstructive pulmonary disease (emphysema) and gastrointestinal bleeding, which likely contributed to his death. �}C6);(b)(7)( documented he could not rule out methadone withdrawal as the cause of death, 162 Basic Life Support airway is an instrument inserted through the mouth, extending into the airway, to keep the airway open. See Exhibit I. 163 See Aurora Fire Department EMS Patient Care Report, dated December 2, 2017. 164 Agonal breathing refers to labored breathing, characterized by gasping. See Exhibit l . 165 Asystole, also known as cardiac flat line, is the absence of heart contractions. See Exhibit 1. 166 Ventricular fibrillation is a life-threatening heart rhythm that results in a rapid, inadequate heartbeat. See Exhibit L 167 See Falk Rocky Mountain Emergency Medical Services (EMS) Patient Care Report, dated December 2, 2017. The Falk Rocky Mountain EMS also reported to DCDF and documented events reported by the ADF EMTs. 168 See GEO Medical Transport Log, dated December 2, 2017. 169 See GEO Medical Transport Log, dated December 2, 2017. 170 See UC Health/AMC Emergency Re ort, dated December 2, 2017 171 See GEO Medical Progress Note b b)(6);(b)(7)(C) ated December 2, 2017. 172 See GEO Medical Transport Log, ate Decem er 2, 2017. 24 2020-ICLl-00006 046 5 7 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS �(b)( );(b)(?)(C);(b)( )(E) but noted that deaths due to methadone withdrawal are rare. He noted SAMIMI had no injuries and no evidence of dehydration. 173 Following SAMIMI's death, DCDF's Warden, Johnny Choate, personally met with each member of security staff who interacted with SAMIMI and provided information on employee assistance services. However, Warden Choate only met informally with nursing staff and did not refer them to employee assistance. ERO sent a letter to SAMIMI's next-of-kin on December 11, 2017, notifying her of his death. DCDF reviewed SAMIMI's death on December 6, 2017, at a Monthly Safety Committee Meeting. 174 CCTV footage was not reviewed for this review. The resulting report stated that both medical and security staff acted properly and in accordance with policy and procedures on December 2, 2017. 175 On December 18, 2017, a committee composed of Warden Choate (b)(5);(b)(?)(C) ;;:: ;-:;;:-;,.."';,:-; .., --,.l(b)( 6);(b)(?)(C) _ p1-et- ed a_, I and a GEO quality assurance representative '"(b�)( 6);(b)(?)(C)---,-c-om_ Multi-Level Mortality Review of SAMIMI' s death. No security or ERO staff participated in the review, and the committee did not review any CCTV footage as part of the review. The committee's findings are purportedly based on the detainee's medical record and reports from medical staff; however, the report contains many statements that are inconsistent with the medical record, and findings that are unsupported by the medical record, which are examined in detail by Creative Corrections. The Mortality Review resulted in one recommendation: "Re­ emphasize to all nursing staff, use your clinical judgment and call 911 when presented with a life or death situation." The committee also identified as strength: "Quick initiation of withdrawal protocol. Monitoring of detainee while on withdrawal protocol." 176 MEDICAL CARE AND SECURITY REVIEW ERAU reviewed the medical care SAMIMI was provided at DCDF, as well as the facility's efforts to ensure that he was safe and secure while detained at the facility. ERAU found deficiencies in DCDF' s compliance with certain requirements of the ICE PBNDS 2011 (revised 2016). 1. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(B), which states, "All facilities shall provide medical staff and sufficient support personnel to meet these standards." • 173 At the time of SAMIMI's detention, DCDF had vacancies in key medical personnel, including a Director of Nursing and a midlevel provider, for longer than six months. See Exhibit 3: Adams & Broomfield County Autopsy Report b��)(5) ;(b)(?)( bated December 6, 2017. Key Safety Committee participants include the Warden, Associate Warden, Chief of Security, Training Administrator, Maintenance Supervisor, HSA, Food Service Manager. 175 See GEO Safety Committee Meeting Minutes b�b)( 6);(b)(?)(C) !dated December 6, 2017. 176 See GEO Multi-Level Mortality Review, dated December 18, 2017. 174 25 2020-ICLl-00006 047 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS (blC5 l;(blC7J:< >;< >< I close medical care, medical staff shall complete a Medical/Psychiatric Alert form (IHSC834) or equivalent, and file the form in the detainee's medical record." • Medical staff did not complete a Medical/Psychiatric alert for SAMIMI. 7. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(R), which states, "An initial dental screening shall be performed within 14 days of the detainee's arrival. The initial dental screening may be performed by a dentist or a properly trained qualified health provider." • Medical staff did not schedule SAMIMI for a dental screening examination. 8. ICE PBNDS 2011 (revised 2016), Medical Care, Section (V)(T), which states, "An on-call physician, dentist, and mental health professional or designee, are available 24 hours per day." • Nurses reported difficulty reachingl;<7>;<7> two disciplines appear to be operating in a tense environment which could adversely affect their communication and responsiveness. • GEO Policy 614, Hunger Strikes, which states, "Detainees declaring and/or identified as being on a Hunger Strike (missed 9 consecutive meals) will be monitored daily." o On November 27, 2017, at 6:59 p.m., the medical officer logged that SAMIMI declared he was on a hunger strike. A supervisor reviewed and signed off on the medical officer's logbook entries approximately eight hours later. Although the log entry indicates security staff were aware of SAMIMI's declared hunger strike, neither security nor medical documentation indicate staff initiated monitoring of SAMIMI pursuant to the policy. ERAU also identified the following area of concerns regarding implementation of opiate withdrawal protocols. • DCDF holds current NCCHC accreditation but failed to comply with NCCHC standard J­ G-07, which states: "Detoxification and withdrawal are best managed by a physician or other medical professional with appropriate training and experience. As a precaution, severe withdrawal symptoms must never be managed outside of a hospital. Deaths from acute intoxication or severe withdrawal have occurred in correctional institutions. In deciding the level of symptoms that can be managed safety at the facility, the responsible physician must take into account the level of medical supervision that is available at all times. Clinical management should also include the use of validated withdrawal assessment instruments, such as the Clinical Opiate Withdrawal Scale or the Objective Opiate Withdrawal Scale in case of opiate withdrawal, and the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, in the case of alcohol withdrawal." o Nurses reported they were unfamiliar with the COWS instrument, and were never trained in opioid withdrawal. Nurses' actions demonstrated a lack of understanding of opioid withdrawal symptoms, including that drug seeking behaviors are expected. Nurses also failed to properly monitor SAMIMI as he withdrew from opioids and to recognize his related life-threatening symptoms. o Nurses did not fulfill the psychiatrist's November 29, 2017 order to complete a daily COWS for SAMIMI. ERAU identified the following concerns related to administration of medications: • Nursing notes did not consistently document justification for administration of as needed medications, or an assessment of SAMIMI's need for medications. • Nurses sometimes refused medications until the detainee ate, rather than provide anti­ nausea medication to enhance his appetite. 31 2020-ICLl-00006 053 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS 4(b)(5);(b)(7)(C);(b)(7)(E) I • Nurses often failed to document the time of medication administration. Per Creative C01Tections, absent documentation of times medications were given, nurses on later shifts could not know when another dose was or was not due. Although speculative, the poor documentation on MARs may have contributed to SAMIMI less than 50 percent of possible doses of medications as needed for anxiety, restlessness, sleeplessness, nausea and pain. • Nurses en-oneously recorded administration of medications on SAMIMI's MAR after he was transported to the hospital. ERAU identified the following concerns regarding nursing care. • SAMIMI's intake screening did not address current symptoms of withdrawal as called for on the screening form. • After intake, nurses did not take SAMIMI's weight again to determine rate of weight loss, which Creative Corrections advises was particularly important given SAMIMI's refusal of meals and inability to keep food down. • Nurses did not make any entries to SAMIMI's medical record on November 19, 2017. • Nurses did not maintain SAMIMI's safety through fall prevention. Video showed incidents in which SAMIMI appeared to hit his head or come close to doing so on the floor or against the wall. • On November 24, 2017, nurses failed to complete a full injury assessment after SAMIMI fainted. • Although, both medical and security staff described him as disheveled and having a strong body odor during their interviews, the nurses stated they did not encourage SAMIMI to shower. • f b)(5 (b)( )(C ) ); ? authenticated. !verbal orders for medications issued November 17, 2017, were not • Nursing notes were brief and inadequate, particularly with respect to subjective information. • Nurses did not write progress notes in SOAPE format. 177 SOAPE charting, a nursing standard of care which provides organized information to other healthcare personnel, addresses subjective information (what the detainee said), objective information (relevant physical examination), assessment (nursing diagnosis based on both subjective and objective information, plan (efforts to resolve, report, or monitor), and education (teaching, directing. and ensuring the patient's full understanding). See Exhibit 1. 177 32 2020-ICLl-00006 054 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS �(b)(B);(b)(?)(C);(b)(?)(El • Nurses did not consistently document encounter times. • Nursing assessments did not consistently document pain levels. • Nurses did not consistently document the justification for giving as-needed medications. • Nurses incorrectly documented verbal/telephone orders. • Nurses did not document completion of assessments for dehydration. ERAU identified the following concerns related to security documentation. • While security staff routinely documented that the detainee was not eating meals, it is unclear whether security staff communicated this to medical staff. On six occasions, officers did not make entries to the Medical Housing Unit Log documenting SAMIMI's acceptance or refusal of showers, recreation, and meals. Missed meal entries include both lunch and dinner on November 29, 2017, which, if refused, total seven consecutive meals SAMIMI refused. • The majority of signatures made by security supervisors and medical staff on the Medical Unit Housing Log forms are illegible. Creative Co1Tections advises that ensuring the staff documenting rounds are easily identifiable ensures accountability. ERAU identified the following concerns related to after-action reviews of SAMIMI's death. • Following SAMIMI's death, facility staff including the Warden, Medical Director, HSA, Quality Assurance Manager, and an RN, discussed the events surrounding the detainee's death at a routine safety meeting and during a facility mortality review. Neither review included viewing of video surveillance footage of the detainee. As a result, conclusions reached during both reviews were based, in part, on incomplete information. ERAU identified the following concern related to maintenance of security equipment. • The medical officer had a non-functioning radio when she made a round on November 28, 2017 and encountered SAMIMI. Security equipment should be regularly checked to ensure its operability in the event of an emergency. 33 2020-ICLl-00006 055 DETAINEE DEATH REVIEW - Kamyar SAMIMI, JICMS �(b)<5);(b)<7) consumed but when she returned to duty for the evening shift, some of the dinner meal remained on the tray. Medical staff signed the log as did a security supervisor. All signatures are illegible. �t DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 071 Page 11 MAR Ativan 9:00 a.m. Clonidine 9:00 a.m. 9:00 p.m. Cyclobenzaprine Given once; time not documented Phener�an Not given Ibuprofen Given twice; times not documented Note: Administration of Ativan was not documented in a nursing note. Note: Ibuprofen may have been given due to complaints of pain during nursing encounters discussed below. The nursing notes for the encounters do not document whether the medication was given, and do not document the justification for giving cyclobenzaprine. The basis for giving clonidine is also not documented as required for as-needed medication; however, the fact that SAMIMI was experiencing symptoms of withdrawal justifies administration of the medication on this and subsequent dates. The conflict is thatl(b)(B);(b)(?)(C) brdered clonidine as needed rather than on a scheduled basis. As noted above, the reviewer cannot verify whether SAMIMI' s blood pressure was checked before he was given clonidine due to the inconsistent and possibly inaccurate timing of MAR entries. Vital Signs Temperature 97.1 98.0 Not taken Pulse 75 65 Not taken Respirations 16 17 Not taken Blood Pressure 104/67 110/74 Not taken Oxygen 95 Not taken Not taken Weight Not taken Not taken Not taken Medical Record A GEO Alcohol Withdrawal Assessment and Treatment Flow Sheet (Clinical Institute Withdrawal Assessment or CIWA) 21 was completed at 1:45 p.m. RN l(b)(6);(b)(7)(C) !stated during interview that she completed the form but acknowledged she did not enter her initials where required. Vital signs (see the first row of the above table) were within normal limits. A score of seven was determined, indicating the level of alcohol withdrawal did not require medication treatment. Note: The CIWA is specific to alcohol withdrawal. Although many of the same symptoms are experienced by persons withdrawing from opioids, there are clinical differences which are factored in scores on the respective assessment forms. RN(b)(6);(b)(7)( I l(b)(6);(b)(7)(C)rtated during interview that she knows that alcohol and opioid withdrawal are clinically different and that she "must have grabbed the wrong form." 21 CIWA is a tool used to assign points specifically to symptoms of alcohol withdrawal, with total scores indicating the severity of withdrawal. It is not compatible with opiate withdrawal instruments (e.g. COWS). DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 072 Page 12 I �b)(5);(b)(?) (C) completed a Medical Observation Nursing Progress Record. He did not record the time. During interview b)(5);(b)(?)(C) guessed that the encounter occurred about 11 :00 a.m. · however, his documentation me u es re erence to times later in the day. Specifically, RN �6\5l;(b)(7 wrote that SAMIMI consumed an unspecified amount of water at 4:40 p.m. and ate 40 percent of his dinner at 4:50 p.m. Vital signs exactly matched those documented on the CIWA, suggesting the same set was used. SAMIMI reported his last bowel movement was the previous day. His skin was warm and flushed, and he complained of headache pain at a level six. Note: �b) (5);(b)(7)(C) I note does not document whether pain medication was given. !completed a Medical Observation Nursing Progress Record. He At 6:00 p.m.J(b)(6);(b)(7)(C) wrote that SAMIMI reported taking methadone over the past 20 years and that he was experiencing nausea at the time. Vital signs (see second row of the above table) were within normal limits. He denied all pain but appeared pale. With the exception of nausea, no signs or symptoms of withdrawal were noted. SAMIMI reported his last bowel movement was earlier in the day, and that he ate approximately 70 percent of his evening meal. The nursing plan was to continue monitoring. Note: There is no documentation Phenergan was given to relieve nausea. Note(b)(5);(b)(7)(C) ntry documents SAMIMI consumed 40 percent of the evening meal; ( b)(6);(b)(7 )( C) entry documents he ate 70 percent. The inconsistency cannot be explained, although it is possible the detainee gave different reports. A 10:00 p.m. progress note written b�(b)(5);(b)(?)(C) !documents SAMIMI stated, "I have pain on my hand and on my back, including my spinal from long time car accident" and that he takes methadone for pain. He was alert and oriented with no shortness of breath or distress observed. He complained of methadone withdrawal s m toms, statin , "M stomach hurts, I am wrote, "Pass to (b)(6);(b)(?)(C) and (b)(5);(b)(?)(C) contact�b)(6);(b)(?)(C) I" shivering." b)(5);(b)(?)(C) During interview (b)(6);(b)(7)(C) statecfb)(6);(b)(7 )(C) was the nurse referred to in her note, and I 7 6 ( ( ( that she believe b) ); b) )(C) ad been notified. Note: The medical record documents no contact or attempted contact with �b)(6);(b)(7)(C) this date. Note: rb)(6);(b)(7)(C) medication. I note does not document whether SAMIMI was given any DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 073 Page 13 Sunday, November 19, 2017 Medical Unit Housing Record SAMIMI accepted all three meals and declined recreation and a shower. Medical staff signed the log as did a security supervisor. All signatures are illegible. Medical Unit Logbook A 7:38 a.m. entry documents, SAMIMI "x-Ray, withdraw". Note: The medical record includes no x-ray report coITesponding to this logbook entry. A 10:40 a.m. entry documents detainee SAMIMI said he was in a Jot of pain and nurses are aware. r b)(6);(b)(7)(C) lwas informed at 10:42 a.rn. and at 10:47 a.m., reported to the cell and gave medication. Note: There were no medical record entries this date to corroborate the officer's entries, although the MAR documents SAMIMI was given pain medication at an unspecified time. The Telmate Phone Record Report documents that at 6:13 p.m., detainee SAMIMI made a free five minute phone call. Reviewers listened to the recording of the call, which was made to an unidentified person. SAMIMI stated he is "dying here" and asked the call recipient to notify his sister so she could post his bond. He also asked what day it was and how long he had been detained. He was told it was Sunday and that he had been there three days. Detainee SAMIMI stated, 'Tm a legal resident" and at the end of the call, stated he was housed in medical and that he was "sicker than hell." MAR Ativan Refused Clonidine 9:00 a.m. 9:00 p.m. Cvclobenzaprine Given twice; times not documented Phenergan None documented Ibuprofen Given twice; times not documented Note: There were no medical record entries documenting the justification for giving medications. Vital Signs No vital signs were documented this date. Medical Record There were no nursing rounds or progress notes in the medical record this date. could not explain why encounters were not documented. DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 074 i;_(b)(7>_ (_c)-,--___,,--___,..,..._,..,...--__,.,.-----------------'I signed ...., the Medical Unit ....,.logbook noting, "All secure." Note: fb>(5);(b)(?)(C) I stated during interview that he did not speak with SAMIMI because he was on suicide watch and sleeping. He said he never met the detainee, but recalled he was discussed at the weekly meeting of department heads on November 29, 2017. It was reported at the meeting that he was on suicide watch and a life-long drug abuser. I In a 9:29 a.m. progress note, fbl(5);(b)(?)(C) documented SAMIMI was on his way to the tele­ psychiatry office when he "threw himself out of the wheelchair, landing on the floor face first." He sustained a nosebleed and urinated on himself. Pressure was applied to his nose with gauze until the bleeding stopped. According to the note, a blood pressure reading was not obtained because SAMIMI would not sta still. Other vital signs (see second row of above table) were within normal limits. b)(5);(b)(?)(C) wrote that SAMIMI attempted to grab him with his bloody hands and was spitting. b)(5);(b)(?)(C) arrived on the scene and ordered that SAMIMI be placed back into the suicide watch cell. The tele-psychiatry appointment was cancelled, and an psychologist, for the following day. appointment was scheduled withl(b)(6);(b)(?)(C) I, l(b)(6);(b)(?)(C) I was asked for his verbal account of this incident. He indicated that when he arrived at SAMIMI' s cell to take him to the tele- s chiatry appointment, the detainee requested assistance in getting into the wheelchair. (b)(6);(b}(?)(C) indicated he declined to assist because he had a knee injury. He stated the detainee was able to get into the wheelchair without difficulty but moved slowly. fbl(6);(b)(?)(C) stated during interview that he was present and witnessed SAMIMI ask for assistance getting in the wheelchair. He saidl(b)(5);(b)(?)(C) ltold him no and that he could do so by his own power. The officer confirmed SAMIMI moved slowl into the wheelchair, but fell out on the way to the appointment. As described by b)(5);(b)(?)(C) SAMIMI lunged out of the wheelchair, falling on the floor. Questioned about this, he said the detainee "definitely lunged" because he landed at a distance which the RN believed required some effort. He said SAMIMI did not attempt to break his fall. l(b)(5);(b)(?)(C) !said the detainee urinated on himself and started bleeding from the nose, adding when asked that there were no other injuries such as a cut lip. He donned gloves and put gauze on SAMIMI's nose, and another nurse anived to assist because the detainee was "rolling around." i_ ,__ <_c)_ ______,!documented SAMIMI ate "half of his breakfast this date." DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 107 Page 47 I l l-L&'.......,.vation which states, "The Cell door will not be opened under any circumstances withou f}'7l( fficers being present and the on duty Shift Supervisor being notified of the need to open the ce . • On several occasions, officers o ened the cell door when detainee SAMIMI was on Level present or without any documentation a shift 1 suicide watch without (b)(?)(E) supervisor was notified and gave approval. DCDF Policy 11.2.31, Permanent Logs and Reports, sections (A) and (H), which state respectively, "Logs will be maintained to reflect the activities of each post or other area on a shift-by-shift basis and to document emergency situations, unusual incidents, and other pertinent information regarding detainees and activities on the post."; and "Make written and oral reports as necessary". • fbl (6);(b)(?)(C) �id not log in the Constant Watch Logbook when SAMIMI was moved from Level 2 to Level 1 suicide watch. • During his shift from 11:00 p.m. on December 1 to 7:00 a.m. on December 2, 2017, �b)(6);(b)(7)(C) I did not document in the Constant Watch Logbook all pertinent information that occurred on the shift. DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 131 Page 71 These lapses also violate the Medical Officer Utility Post Orders which require the officer to document "any unusual occurrences". DCDF Policy 17.1.2 Sanitation Procedures, section (I), Blood or other body tluid, which states, "Following any incident where there is spillage of blood or other body fluids the area shall be sanitized immediately by a member of the health service staff. . .". "Medical staff will utilize "Clean-Up Kits" to clean up any blood and body fluids as well as decontaminate the area"." Security staff are responsible to ensure the area is secure and that all persons entering the area are donning appropriate personal protective equipment. • Security personnel are being required to clean up bodily fluids such as urine, feces and vomit. Medical personnel are only cleaning spills that contain blood. The Security Chief believes medical staff should clean any spills in accordance with the policy. The HSA believes that medical staff should only clean spills containing blood. The lack of adherence to the policy and the disagreement between the Security Chief and HSA has contributed to the tension between the two disciplines. The policy needs to be followed or amended. GEO Policy 614, Hunger Strikes, which states, "Detainees declaring and/or identified as being on a Hunger Strike (missed 9 consecutive meals) will be monitored daily." • At 6:59 p.m. on November 27, 2017, the assigned medical officer documented in the logbook that SAMIMI informed the officer he was "on a hunger strike." There is no further documentation in the logbook. This notification by the detainee should have triggered daily monitoring. A supervisor next reviewed the logbook at 3:20 a.m. and supervisors are required to "review and sign the log" in accordance with the Permanent Logs and Reports policy noted above. No action taken as a result of this statement is documented. Areas o(Note • On six occasions, officers did not make entries to the Medical Housing Unit Log documenting acceptance or refusal of showers, recreation, and meals. Missed meal entries include lunch and dinner on November 29, 2017. If refused, SAMIMI did not accept seven consecutive meals. • Most signatures of security supervisors and medical staff on the Medical Unit Housing Log forms were illegible. Ensuring staff documenting rounds are easily identifiable DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 132 Page 72 ensures accountability and that the proper staff can be contacted when additional information is needed at a later date. • While security staff routinely documented that the detainee was not eating meals, it is unclear how this information was communicated, if at all, to medical staff. • The medical officer had a non-functioning radio when she made a round on November 28, 2017 and discovered SAMIMI with a sheet around his neck. Equipment should be regularly checked to ensure its operability in the event of an emergency. • The GEO track system erroneously documented the date and time of the detainee's placement on suicide watch. • The GEO Suicide Watch Log and Notes form #HS-207 lists Level 1 as "Constant Observation" while the DCDF post orders for the Medical Utility Officer refer to Level 1 as "Continual Observation". The GEO Suicide Watch Log and Notes form #HS-207 lists Level 2 as "Fifteen Minute Checks" while the DCDF post orders for the Medical Utility Officer refer to Level 2 as "Constant Observation" requiring 15 minute checks. The forms and post orders should consistently define the two levels to avoid staff confusion. DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 133 Page 73 APPENDIX 1 SAMIMI VITAL SIGNS l(b)(B);(b)(?)(C) I ordered that vital signs be taken every eight hours. The below table lists vital signs documented in nursing notes and blood pressure documented on the Blood Pressure Record on November 25, 30 and December 1, 2017. Shaded areas indicate missing vital signs. DATE TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE OXYGEN 11/17/2017 98.2 94 16 130/94 100 97.1 75 16 104/67 95 11/17/2017 11/17/2017 11/18/2017 11/18/2017 11/18/2017 97.9 98.0 75 65 21 17 146/94 110/74 11/19/2017 11/19/2017 11/19/2017 11/20/2017 94 16 97.6 87 98.2 11/20/2017 11/20/2017 11/21/2017 11/21/2017 11/21/2017 11/22/2017 11/22/2017 11/22/2017 11/23/2017 11/23/2017 11/23/2017 11/24/2017 11/24/2017 11/24/2017 11/25/2017 11/25/2017 130/94 100 16 118/76 95 82 17 108/74 99 98.1 82 16 107/74 97 98.2 102 18 128/83 93 76 16 16 127/93 134/93 98 111 16 107/81 99 92 16 126/78 96 97.8 98.8 97.8 11/25/2017 11/26/2017 11/26/2017 11/26/2017 98 97.6 76 77 91 71 16 18 16 DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 106/76 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 134 134/93 129/85 117/88 125/85 98 96 96 96 Page 74 98 12 124/80 95 98.1 107 18 124/91 95 97.7 120 16 108/82 100 88 16 100/70 95 84 16 101/64 11/27/2017 11/27/2017 11/27/2017 11/28/2017 11/28/2017 11/28/2017 11/29/2017 11/29/2017 11/29/2107 11/30/2017 11/30/2017 11/30/2017 97.6 97.8 12/01/2017 12/01/2017 94 12/01/2017 12/02/2017 12/02/2017 100 98.2 92 100 15 18 17 17 DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 135 101/70 100/76 99 96 112/68 113/68 92/68 94 95 Page 75 APPENDIX 2 SAMIMI MEDICAL HOUSING LOG DATE MEALS SHOWER RECREATION 11/18/2017 3 No No 11/20/2017 3 No entry No entry 3 No No 11/19/2017 11/21/2017 11/22/2017 11/23/2017 3 3 3 11/24/2017 0 11/26/2017 1 (breakfast) 11/28/2017 2 (breakfast, lunch) 11/30/2017 0 11/25/2017 11/27/2017 11/29/2017 12/1/2017 0 0 No No No No No No No No No No No Yes No No No SUPERVISOR ROUNDS Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No entry Yes 1 (breakfast); no entries for lunch and dinner No entry No entry 1 (dinner) No No No No DETAINEE DEATH REVIEW: Kamyar SAMIMI Medical and Security Compliance Analysis March 6, 2018, revised March 14, 2017 _l C MEDICAL ROUND 're:ali1t,e i::11rii111eti1111:s 2020-ICLl-00006 136 Yes Yes Yes Yes Yes Yes Yes Yes Yes No entry pt and 2 nd shift Yes pt and 3'd shift Yes Yes No entries Page 76 General Incident Report The GEO Group, Inc. -Aurora/1.C.E. Processing Center Subject: Please check one of the appropriate boxes □ Security Breach □ Major Fire W □ Contraband Med. Emergency To: b)(6);(b)(7) (C) From: □ □ □ Rules Violation Minor Fire Maintenance D Hunger Strike Title: L Title: 1:/u l(b)(6);(b)(7)(C) Detainee: D D D D ' I � �•/Lt( Print-a me k.uflfrf. Print Name {,{ V° ID# ID# ;?-7,,J :;.c;1?I Detainee on Detainee Assault Self Harm Ma/or Disturbance Other: Date: I Location: .,..._vf(n .f :vfp Time: !/ DO Print Name ID# Dorm Dorm Print Name ID# Dorm (Please Print and Include: Dateffime, If AOD was notffied, whe and by whom) j l:':)' Minor Disturbance orm Supervisor's Assessment � Detainee on Staff Assault Detainee Injury Detainee: Details of Incident SAL D p D � 2020-ICLl-00006 137 General Incident Report The GEO Group, Inc. - Aurora/1.C.E. Processing Center Subject: □ □ □ □ To: Please check one of the appropriate boxes Security Breach Ma/or Fire Med. Emergency Contraband □ □ □ □ b 6;b 7 f )( ) ( )( )(C) Minor Fire Maintenance Hunger Strike Detainee on Detainee Assault Self Harm Major Disturbance other: □ □ □ Detainee on Staff Assault Detainee Injury Minor Disturbance Date: 1--;}- :;}- \J Time: 1 l ?:lO Tltle:�N§PoQ;t: Location: � -A v � W: - __ _ _ � �------Title: From: l(b)(6);(b)(7)(C) Detainee: □ □ □ □ Rules Vlolatlon �tJ.JrE{\{A-� '::>4N I N 1 1 � 'l � d,:l, 3:)qtft,Detalnee: Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Details of Incident (Please Print - Who, What, 1-'Vhen, 1-'Vhere, How &Why. You Must State Facts And Absolutely No Editorializing) 01')� �� }U.AN'?io•g:c !2fEi c.bf, l,M ve .Do "1S? A i'¼QllAl, tEIY\f&bf:;N(\J. 'I. '-AN6 Ar0\)1\J.Q 8AUL TQ e.,\ c& 1 1',J �MQ.v �CGr \t,,, L::r\,! t)G-t:Pr INS6 } ,NS:,c.G ME,O, L £iec .C'E£T ANO w TbA-h\ �€:rt&: \Nt&- Y'!t'!"',;, Th'Lk.-N iI\ITQ AN€-Q., R@M \.blu,f& k l, �-X 180ci Supervisor's Assessment rv--r� (Please Print and Include: Datemme, if AOD was notified, when and by wflom) >--u- .Sv..�v,� svvi11 tt...�· (b)( 6);(b)(7)(C) C2'2--vil@? Po ame an'lf Title e._ 2020-ICLl-00006 138 TRANSPORT/ESCORT LOG b)(6);(b)(7)(C) J I ....1------ Escorting Officer (s) L___ (Print Name) J (b)(6);(b)(7)(C) L. ____.,..__________ (Print Name) / .... '1'-'0 _3�0'-------=-______ Time of Return____,\'-- S Time of Departure __._I _._ Vehicle Used: Model L12Jo Make LJ 9 i3_3'-,3J.-_"o_S"---"'o'---_ Starting Mileage: __ �oW VIHV Ending Mileage: 2;>,] C> S: 2} DESCRIPTION OF EVENTS TIME (b)(6);(b)(7)(C) Supervisor Signat L_____________..t-- Date: Ja-a.- 17 Transport Officer Signature: __________ Date: _________ ORIGINAL: Transportation Lieutenant CC: Business Office :HSA 2020-ICLl-00006 139 Aurora/1.C.E Processing CenCer 3130 N. Oaldand Stnet Aurora, Colorado 80010 The GEO Group, Inc. TRANSPORT/ESCORT AUTHORIZATION Detainee Name ,Sq rn i' (11 , ' I H�sing Location____ kgr11 ''J� fl... 10#_____ Custody Level____ Alien Number PURPOSE OF TRIP a-,,3-0_0....,q-y.,..,k-- Emergency,MedicaiX Oocto(s Fed. Tax ID# ... Authorization#d,0( ;1·, ·( L Un ,,.; Ot O � Basis for Escorted Trip· (Explain Briefly) 1rctl' "J,�f<, tro/'"'i b )t !_cf::_�'7 /Q d� 7.JJ'11f{ Othe.r..---___ i/oM,-f-,y. 4., pq,l=-/U-d,,j ·-� @bf;<1 f' d I ctc /}R12.e.s-f H'C$/l< I,✓ rfr ;· lef � o()_. I� i-------�----· . · Date: . c > ·)kl"} )"$f} iJ t- .,,...b)=(6,....,,);(b...,...,)(7=)(=c)-------, UB1ack eox Restraints Required: H a Reviewed by Cla t· \ Date:_fil_t:ilf\- Additional lnfonnation (pro,,_-.ny,..... ......,._........._,,,,_rnv.llllllRJing detainee's prior 1'8001'd, unusual circumsfanoes, special precautions to be taken, etc. Reviewed By Captain (comments and recommen dations)___________"""";· ·:...--- · �fn's Signature:.__________ ·------- Da�: Reviewed By AsslstantWarden-Security (comments and recommend8tions)_________ Assistant Warden's Signature:._______ ___ Date:_______ APPROVAL / Warden DISAPP/- · . . __Disapproved APPl:oved (Comments)-����----,------..;.,.-----------­ ;0.2 mi) (at cad03) on 2017-12-02 11:16:03 - **No recommendation for requirement CFO 61 or CFO 62 or CFO 63 or SABLE or SMF (at cad05) on 2017-12-02 11:16:31 - NFI (at cad0l) on 2017-12-02 11:21:50 - pe3 - cor-0 (at cad0l) on 2017-12-02 11:22:09 - **LOI information for Event # Fl7052112 was viewed at: 12/02/17 11:22:09 (at cad0l) on 2017-12-02 11:22:09 - **>>>>by: pn terminal: cad0l l(b)(B);(b)(?)(C) (at cad0l) on 2017-12-02 11:22:15 - **LOI information for Event # Fl7052112 was viewed at: 12/02/17 11:22:15 (at cad01) on 2017-12-02 11:22:15 - **>>>>by: n terminal: cad0l fb)(B);(b)(?)(C) For: 314407 Monday December 11, 2017 Page: 2 of 3 2020-ICLl-00006 146 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-396984 Reported: Dec-02-2017 11:22:04 Clea rance Information Fina l Ca se typ e : Cancel - No Units Dispatched Re p ort exp e cted: No Founded: Yes DispatchDeta ils Unit number: 105 Disoatched: Dec-02-201711:22:27 Officer 1: 315181 j(b)(6);(b)(?)(C) Enroute : Dec-02-2017 11:22:47 At scene: Dec-02-201711:32:47 Cleared: Dec-02-201711:38:52 Dispatcher ID: 315629 I Unitnumber: 108 Dispatched: Dec-02-201711:23:04 Officer 1 : 315184 ICb)(6);(b)(7)(C) I Enroute : Dec-02-2017 11:23:08 Cleared: Dec-02-201711:23:17 Dispatcher ID: 315629 Unitnumber: 106 Dispatched : Dec-02-201711:23:13 Officer 1 : 301038 �(b)(6);(b)(?)(C) I Enroute: Dec-02-201711:23:19 At scene: Dec-02-201711:26:58 Cleared: Dec-02-201711:43:04 Dispatcher ID : 315629 Unit number: 103 Dispatched : Dec-02-201711:33:10 Officer 1 : 301024 �(b)(6);(b)(?)(C) I Enroute: Dec-02-2017 11:33:13 Cleared: Dec-02-201711:37:31 Dispatcher ID : 315629 Unitnumber: CR3 Dispatched: Dec-02-201711:33:11 Officer 1: 18566 -ICb)(6);(b)(?)(C) I Cleared: Dec-02-201711:36:51 Dispatcher ID : 315629 Unit/Office rDeta ils ** END OF HARDCOPY ** For: 314407 Monday December 11, 2017 Page: 3 of 3 2020-ICLl-00006 147 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-397093 Reported: Dec-02-2017 13:12:04 Incident Location Address : 3130 N OAKLAND ST Place Name : in GEO CORRECTIONS DETENTION City : AURORA District : 1 Beat : 3 Grid : 2D2 General Information Report number: Case Type : INFORMATION Priority : 4 Cleared : Dec-02-2017 13:12:04 How call received : TELEPHONE Call taker ID : 248910 Complainant Information Name : BROOKE ADAMS COUNTY City : 2 State : CO Remarks : Dec-02-2017 13:12:04 - WANTED INFO ON PARTY TRANSPORTED AT 1140, ADV'D HER THIS IS FEDERAL FACILITY AND TO CONTACT FEDS (at cad03) on 2017-12-02 13:12:04 - WANTED INFO ON PARTY TRANSPORTED AT 1140, ADV'D HER THIS IS FEDERAL FACILITY AND TO CONTACT FEDS Clearance Information Remarks : E911 CALL UNFOUNDED Final Case type : HANGUP/UNFOUNDED/CANCELED Report expected : No Founded : Yes Reporting Officer! : 248910 Dispatch Details Unit/Officer Details ** END OF HARDCOPY ** For: 314407 Monday December 11, 2017 Page: 1 of 1 2020-ICLl-00006 148 12/04/2017 (FAX) 11: 46 Fa I k ' Falt« . . . :-. . .. . ...... .. . Date: /J- 'l-11 . r· FAX COVER SHEET FOR FALCK ROCKY MOUNTAIN x,,,,.)(IXc, __._1.____�-Attent,on:___ L FrC?m: !f/AJlc1<'1!4cb.i-fh� D �i'� · Fax Number: 3CJ3 · · Regarding Claim #: ______ Number of pages including cover sheet:� a� Claims Department: Falck Rocky Mountain -NPI 1528446820 TAX ID 473265252 Billing Office Address: = .,,....,..,,,.,."""'= 7 . 1201 S Alma Sc�oof Rdfbl (5J;(b) ( l (cJ-----,I. Mesa, AZ 85210 r)(6);(b)(7)(C) Bifling Specialist ...........,.,.�,=---------, Phone # 480�(bL.. )_(6);- (b)(- ?)(c_ , _____ FAX# 480-912-7565 ...) ""-·- 2020-ICLl-00006 149 P.001/006 (FAX) 11:46Falk 12/04/2017 ■ FINAL P.002/006 ame Patient Care Report ini Falck Date of Service: Run#: 47787 Falck Rocky Mountain AFR#: 10703 East Bethany Drive Aurora, Colorado (72 0Jb)(6) ;(b)(7)(C) I 12/0212017 Dest Fae MR#: 5960219 80014 ___,I I....__R_E_S_P_ O_N_ S_E--'IN_F_O__....,I ._I ____D_IS_P _O_S_IT_ OI _N___�I ,._I __TlM=E S---,-:-.,,....,..-' lnjwy: 11:15 12-02-17 Dutlnatlo1< Anschutz lnpaUanl Pavilion Locallon: 3130 N OAKLAND ST '----�C.;.; RE F�O__ .;..;....;.;.IN ;;;;;W ;.;. Unit 0646 Nrtu,eOR:alt Vthlclo: 108 Ooc'd By. Kb)(6);(b)(7)(C) c...w 111D: !(b)(6);(b )(7)(C) I Crow2Role: Driver-Response, Drtver-Transport, 0th« Pallenl Caregiver-Al Scene Crowl l.aftt EMT-Basic Crow 1310: Crew.I Rolr. Cr•W3 Lave!: Rosp.wllh: AFREnglne3 Lo•el of 1h11 ALS.Paramedlc Unit: Olhor Aa• ncy. UnitTyp• ALS Nome : Kamyar Samlnt BSN: 000-00-0001 Se1t: Ma la Belongl"II•: Belan9lng Loll With: Race : Other UNK PROBLEM (PERSON OOWN) STANDING, SITTING, MOVING. OR TALKING ~· '8.AP; 11:16 1 2"2 1 7 01., Notify: 11 :1612-02-17 it.cw: 11:16 12-02-17 Olopotr:lt 11:17 12-02-17 En routo: 11:17 12-02-17 Outcorno: P aijent n, t ati,ransport Cond al Out.: Unchanged Dul Rtoao« Closest Appropriate FecUlty Acuity at Dloprtch: lnlllal Pt. Acuity: Atocono: 11:19 12-02-17 Al potion!: 11:21 12-02-17 TraO!Ca..: Tra,.pOlt 11:38 12-02 1 - 7 RHp Priority. Immed a i e t Lights & Siren Ald111L: 11:41 12-02-17 Trans. PrlorHy. I mmediate lights & Siren Ou1Tta 11:44 12-02-17 ;r.:/ 12:16 12-02•17 In .. s� Ool•Y : Non&'No Delay RHp.Doloy: None/No Delay c.ncet Atbuo: Trano. Dotay: None'No Delay Oeat Delay. None/No Delay Protocolo: NrModArr. EMScan emp 12:16 12--02-11 Al Scene Mlloa: 0.1 Sool Po■lt/on, Al DKL MIia: 2.2 Hols,hl ofFall: Samora lo Co"': None Noted Nona IP18onSceno: Single Pl Mv'd to Pre.rn.: • P1o Tran•pfct 1 Sl1'9tcher >t Moved from Pram Supine• Caniad, Slretchar Triage Clan.: IIHo Cuua lty: No Activity at Orwot: R8cv0octor, PoH. lnju,y: No RHponM Zone: Aurora_BAFB Home Count,y : DOB: 01 /03/19 53 (64 yrs) Waight: 130.00 lb$ 58.97 Kgs llroaelow/Luten DLlnfo: nlted Statu HameAddr,: UNKNOWN AURORA,ARAPAHOE, CO 80010 Moblle No.: (303fb)(6);(b)(7)( ! MIiiing Addr. Namo: Phone : Sex: HomeAddr.: SSN: {AIP) 12fi05 E 16TH AVE Aurora, Adams, CO 80045 Twooflorvlcc S'8na Response LocnType: Prison ! C......, Rolo: Olher PaNenl Caregiver-A l Soena, Olhar P aUent Caragl\ler-Transport Crow1 L.,..t EMT.Paramedic Crow#2 ID: !(b)(6);(b )(7)(C) .;.;;.:.;; .;:;_ AUROOA, __, CO 80010 NEXT OF KIN Relllllan•lllp: DOB: Celt Phone:: INSURANCE no Insurance lnfonnatlon entered. PATIENT COMPLAINTS Chi•( CompteJnt Cardiac Arrest (Primary) 5 Minutes Anatomic Location P age 1 of5 2020-ICLl-00006 150 12/04/2017 11: 46 Fa I k ■ Fl NAL P,003/006 (FAX) Patient Care Report Kamva Falck Date of Service: a6ent Name ; j Samini 12/02/2017 Run#: 47787 Falck Rocky Mountain AFR#: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 Chest Ocsansntem Cardiovascular Primary Svmntom CardiacArrest Other Au oehrted Symptom, CardlacArrest Lail PCII Intake MpdtcalttxObblnpdECPm HISTORY Put Mpdfcol History Unresponsive No Known Drug Ale,gy No Known Envtronmanlal/Food Allergies Medications Unresponsive ASSESSMENT PhyslMedlcal/Manlal Limit Req Amb Setvlee Pt. Can1 Rec@ Send Fae ETOtt'Onlg use: Nona Reported I12/02/2011 1:1:24:00 BoclvA,:"H Airway Cln:ulation _ Extemal/Skln Neurological Pdm■rv 1roeress1°o; By; �DJ(6);(b)(7)(C) A.1Hfffflln11 IOd Comm,ata Patent BodvAroa Pulses - Carotid • Absenl (0) Blood/Fluld LO$$ None Noted Normal Mental Slatua Unresponalve Nol Done Cardiac Attest Breathing Aflflfrn•oll and comments Absent IMPRESSIONS Page 2 of S 2020-ICLl-00006 151 12/04/2017 ■ FINAL P.004/006 (FAX) 11: 46 Fa I k Patient Care Report Falck r Samini Date of Service: 12102/2017 Run#: 47787 Falck Rocky Mountain AFR #: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 CARDIAC ARREST Cardiac Arrest Yes, Prior to EMS Arrival Armst EHotoav Cardiac (Presumed) ResuscHation Attempted Attempted Defibrillation Arrest w;toesacdby Witnessed by Lay Person EicstMonHored Rhythm Asystole Spontaneous Cir culation Attempted Ventilation Initiated Chest Compressions No 12:00 12-02-11 Resuscltatjon Disc pate/Hme Dlscontlpued Reason Medical Control Order RhythmatPesttnaHon Asystole CPR Types Compressions-Continuous Ventilation-Bag Valve Mask Ti meofcardjac Arrest 2017-12-02 11:19:00 CPR Prov1g,g PrjortoEMS ctct No AED Used Prior to EMS Cara No END OF CARDIAC ARREST EVENT Expired in ED CPR ProvidedBv I First Responder (Fire, Law, EMS) TRAUMA I cause ofIDIYfY Method of Injury - Not Applicable Time fJA le 121212011 11:23 No J Pulse o, Absent; Regular VITAL SIGNS � Monitor Rate Re19jg,tgry O oApne1c, E1 +Vi +Mi" 3 Skin Temp=Nonnal Skin Color-Normal Skin Moisture=Normal Cardiac Rhythm=Asystole Pupil size: Lefl=4-mm, Rlght:4-mm Pupil Reacts: Left:::Non-Reactive, Right=Non-Reactive Level of Consciousness: Unresponsive; Arm Movement: Lefl=None. Right=None; Leg Movement: Left=None, Right=None; Heart Rate Mearuremenr-Palpated Taken by: no trauma scores entered no prior sld entered no treatments entored TRAUMA SCORES PRIOR AID TREATMENT SUMMARY Page 3of S 2020-ICLl-00006 152 12/04/2017 11: 46 Fa I k ■ Falck FINAL P.005/006 (FAX) Patient Care Report Date of Service: 12/02/2017 Run#: 47787 Falck Rocky Mountain AFR #: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 NARRATIVE M108 dispatched with E3 for an unknown medical. Arrived on scene to find a 64 yoM lying supine on the ground with CPR in progress by AFD personnel AFO reported the pt still had agonal respirations at a rate of 2 a minute upon their arrival. Pl was in asystole on the monitor. Pt recieved a total of9 rounds of CPR. Pt remained in asystole uni� the 8th round of CPR. On the 8th rhythm check, the pt was in V. Fib. Pl was shocked once. Upon next rhythm check, the pt was back in asystote. An 10 was placed in the pt's RIGHT tibia. Saline w pressure bag hung. Pt was administered 3 rounds of Epi. Epl was given at 1130, 1134, and 1139. An red OPA was placed. A size 4 Igel was placed. Pt was ventilated with a BVM with 15 LPM of oxygen. Pt's capnography remained arourid 22 throughout transport. No obvious trauma was noted on the pt. Pt was found in a suicide watch room. Pt was in that room after he attempted to hang himself last week. Pt was transported emergent to AIP for further assessment AFO Engine 3 maintained patient care throughout transport. Paramedic R. Wilson MISCELLANEOUS no mlsce/laneov:s entered !lllll 12/02/2017 11 :59 SIGNATURES � Who IIADtd Nurse (RN) - L, Kil FacMity Acceptance The patient, Kamyar Saminl, was received by this facility on the dale and al the time indicated and this facility furnished care, services or assistance lo the paHent My signature is not an acceptance of financial responsibility for the services rendered. b)(6);(b)(7)(C) 12/02/2017 15:41 Why Pl11eot did nphlgn Crew - No Patient or Auth Rep Signature Crew Member #1!(b)(6);(b)(7)(C) CPR In Progress My signature below indicates that, at the lime of service, the patient was physically or mentally incapable of signing, and ttiat none of the patient's authorized representatives were available or willing lo sign on the patient's behalf. My signature, in part authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided lo the patient by Falck Rocky Mountain, Inc. My signature is not an acceptance of financial responsibility for the services rendered. b)(6);(b)(7)(C) CREW INFORMATION ss,o P•lt(Ifrno · � 115 1210212011 09:08 ti9Da �(b l -)(6- );-(b-)(7-)(-C)-� Cr:,w1 State IP 0151100 � EMT-Paramedic -'.a:d 202 tilmo �Kb-)(6_) -;(b-)(-7)-(C-)--� Crew2 Stal" IP 0161091 EMT-Basic Lim Pacie 4 ors 2020-ICLl-00006 153 12/04/2017 FINAL (FAX) 11:46Falk ■ Patient Care Report Falck 12/02/2011, {". Run#: 47787 . I•:· Date of Service: Falck Rocky Mountain 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 b)(6);(b)(7)(C) P.006/006 AFR#: Dest Fae MR#: 59 6 I��...� . l. •�" 021 ! .i \. ·J' (b)(6);(b)(7)(C) ·• :,= ·, : j. ! ,: Peqe 5 of5 2020-ICLl-00006 154 AURORA FIRE RESCUE INCIDENT REPORT REQUEST Send request via email to flre@auroragov.org: or via fax to 303-326-8986; or bring In person or mall to: Aurora Fire Rescue 15151 E Alameda Pkwy, Suite 4100 Aurora, CO 80012 Please note: It may take up to 5 days to process your request. Today's date: _1_2/_1_1_/2_0_1_7______ Requester Information )(6);(b)(7)(C) Name: kb L Address: 31 30 N. Oakland ( )(6);(b)(7)(C) b 303 Phone#: _ _..]! _______ ...______ City: Aurora State: CO Zip: 80010 -=-=------''----------------------------- St. Relationship to Incident ICE Supervisor VaIid ID# (Only needed if requesting medical information) Requested lnfonnation (Check report needed) D Ia Fire Motor Vehicle Accident I Requester signature: tb)(6);(b)(?)(C) 0 Patient / Medical 0 Other EMS Resoonse ( )(6) (b)(7)(C) . Email� b ; Would you like to receive the report by mail, by fax, or pick up in person? Provide fax # I email address Incident Information Please fill out as completely as possible. Incident Date: 1 2/02/ 201 7 Incident time: 1130 am Type of Incident: EMS Resoonse and transoort hosoital Address of Incident: 3 1 30 N. Oakland St. Aurora. CO 80010 Persons (s) Involved: �S::.:.im:.:.:.:.:im.a.:..:.ii....aK..:.,am ::.:. =ya�r,____________________________ This signed form may serve as the necessary medical release in applicable requests. All reports are subject to review and approval prior to release to any individual or company. FOR OFFICE USE ONLY ------ Date: R8"iewed h\f: r)(6);(b)�)(C) EMS Approval: Ll ___________;------- Approved for release: D Yes D No Arson Approval: Comments: Report Type # Copies Basic Incident Report Cost Total Paid Suoolemental Reoort lnvestii:iation Report Photos PCR D E-mailed D Faxed D Mailed D Picked up Date: ------ By: 01-38 Rev.11/15 2020-ICLl-00006 155 Aurora Fire Department- EMS Patient Care Report lncident;ooo o1-2011 -oooo52111-00000 (Patient Number 1isamJnt , Ramyar I] II !Incident Information Incident Location 3130 N Oakland Street (80010) Incident Date/Time 12/02/2017 11:13:46 Station District Aurora Station 3 (Emergent) B Shift Transporting Unit Medic 108 (Emergent) Shift uncident fime Log II Unit: Dispatched Engine 3 11:16:03 l(b)(6);(b)(7)(C) Medic 108 Battalion 1 11:17:55 11:21:53 11 $aminl, Kamyar lncident;ooooj-20J2-oooos2112-ooooo (Patient Number Responding On Scene To Hospital At Hospital In Service 12:10:30 11:18:14 11:16:39 11:18:34 11:22:16 l(b)(6);(b)(7)(C) _______.I (EMT 11:44:16 II 11:45:59 11:39:58 11:26:59 Paramedic) inctdent;ooo01-2017-000052112-00000 samtol , Kamyac 2020-ICLl-00006 159 II Page 4 of 5 Aurora Fire Department- EMS Patient Care Report No patient documents collected. Report authored by:�b)(6);(b)(7)(Cl 2020-ICLl-00006 160 Page 5 of 5 FAX TRANSMITTAL Corrections & Detention ® Date: 12/3/17 To: Adams County Coroner Phone:303{blC5l;(blC7lCCl Fax:303-655-3530 cc: RE: Fro Aurora Detention Center GEO Corrections & Detention 3130 N. Oakland Street Aurora, CO 80010 1(b)(6);(b)�)(C) TEL: 303K b)(6);(b)( I FAX: 303-341-2652 www.geogroup.com Phone: 303-ICblC5l;CblC7HCl Fax: 303-341-2652 email: �b)(6);(b)(7)(Cl # pages including cover: I Yr "?'f-/4.,( REQUESTED MEDICAL RECORD FOR CORONER CASE #Al 7-03073 Attached is the facility medical record for detainee Samimi, Kayar as requested for Coroner case #Al 7-03073 CONFIDENTIALITY NOTICE: The acco111pa11y11 ed solely for 1he use es1g11a1ed below. ed. Delive,y. dis1rib111io11 or dissemi11a1io11 of 1his Doc11me111(s) 1rt111smi11ed herewith may co111ai11 in or ·• , .e 1101ify us by 1elepho11e. , ressee. is s11·1c1ly prohibi1ed. lfyo11 ha,·e recei,·ed 1his acs1 comn11mica1io11, o/her 1ha, 2020-ICLl-00006 161 303-65�]-4 718 11-29-'17 15:06 FROM- T-461 P0001/0001 F-939 Offk't' Corotw1"1i" M<>11'1ktt i\l"(m,:11Gi:1•1m-d1111 C(•fl\'1li;11 co :�.1 (1 N. I •ii.ti --- • ll'l'•ll, 81.)61) I Pl<'-J�� .iO. L...-___.r,.• :J.\fl.i\:'.tUSJO FAX TRANSMJTTAL ADAMS COUNTY CORONER Requestfor Records Date: 12/2/2017 Time Faxed: 3:05 pm I Needed By: ASAP To: ICE Detention Facility Fax#: (303) 341-2652 Re: SAMIMI, Kamyar Date of Birth: 01/03/1953 Date of Death: 12/02/2017 SSN: Coroner Case#: A17-03073 CR#: Time of Death: 12:02 To Whom It May Concern: The Office of the Adams County Coroner is reviewing the death of Kamyar SAMIMI. This office is responsible for determining the cause and manner of death. A review of records, maintained by your agency is a necessary and material part of our investigation and will assist in the accurate and timely determination of the cause and manner of death. Therefore please fax the following requested records Pursuant to Sectio n 1. 30-10-606 (6), Colorado Revised Statutes and 45-CFR Sec. 164.512, to (303)�b)(6J;(b)(7)(C) I Thank you for your assistance. Progress Notes Nurses Notes operative Report Doctors Notes Consultant Report COR/Death Summary Police Report Medication Log EMS/Fire Trip Sheet Lab Summary Other Document(s): Most recent 2 week admittance lncid&nt Location/Transport&d from: Comments: 3130 N Qakland St Thank Youl 2020-ICLl-00006 162 Date of Trans: 12/2/2017 12:02 TO THE PATIENT: You have the right., as a patient, to be informed_.,_._..,........,......_...,......--.....--.......---�-.-, the recommended mental and physical procedures to be used fot finding out about your problems, and the benefits, risks and hazards involved in the treatment provided to you by the staff at this unit This disclosure and consent fonn is not meant to scare or alarm you, b11t is simply a method to better infonn you about your recommended treatment. \/TREATMENT BY MEDICATION: Treatment with psychiatric medications will be based on decisions made by a doctor. , The method of giving the drugs and the amount of drugs will be monitored by the treating doctor. You will � be informed by the doctor ot his/her assistants of the f<¥lowing: .. ' I. The expected results of the medicines and the side effect�, hazards, and risks involved with taking those medicines 2. The1>enefit or good effects that you will receive from taking the medications 3. Treatment with these kinds of medications may be forced on you if two doctors agree that you are a danger to yourself or others, or that you are unable to care for your b3:-ic needs. . . \ � TREATMENT BY COUNSELING: A trea:tmeot plan will be : HS121 4:•. }\ '..t. ...• ,�. ther(describe): l>1>'-IL�� ( �o-.Le.d J.,u..•°t � b � Eye Contact oor o other descn"be : 2. Attitude -----------...!.... -------------------- no unusual movements or Appetite: □ WNL o incr psychomotorchanges Sleep: □ WNL o . □ other describe : ormal rate/tone/volume w/o pressure o other describe : □ blunted ctive & mood congruent o depressed o labile o normal range o constricted o other describe : o tearful □•flat ·eus �uthymic a irritable o depressed tAJ1/d � e □elevat� .. . � � □ other descdbe : o disorganized oal•directed and logical a other describe :· Suiddal ideation: one a passive o active Homicidal ideation: o active If active: plan YIN intent YIN means YIN If active: plan YIN intent Y/N means YIN 3. Behavior Appetite/Sleep 4. Speech 5. Affect 6. Mood 7. Thought Processes 8. Thought Content ... . I 9. Perception '. 10. Alert/O�'11tation '' J ' :,. . a o er -� ; .. '•.,. ' �- ,, ong tenn intact o distractible/inattentive 11. 13. · Comments: . .. o phobias o delusions □ obsessions/compulsions describe:· ucinations or delusions during interview I ) b)(6);(b)(7)(C) J Mental Health Rev l/14 HS-158 - ,_ - - -- · - · - ..... � Inmate Name: Samimi, Kamyar - - - Inmate#: . \ , .. , Progress Notes -· 008: ' 1/3/1953 A22732918 - Facility Name: .. - Aurora Det.ention Center 1, Date: Comments: 11/20/1713:1513:40 S; "'I was taking methadone." [Client in withdrawal and housed in medrcal at present.} 0: M.H. Evaluation completed. Denies HX of SI/HI, self-harm, ETOH use, DV, SA, violence toward self or others. ·Client reports first use of opium in Iran when he was 4-years-old. "My grandfather was a doctor, and he gave it to me for an ear ache." However, client says that he first made a decision to use opium as a substance at 14 years old while stitl in Iran. Client came to the U.S. when he was 20, attended university in CO and Wisconsin. Before being detained by ICE, client says he was self-employed as an auto technician. Client says he eventually migrated to opiate prescription medication and that a mental health professional initially prescribed methadone in 1991, "She thought it would make me feei better." Client also reports one arrest for _QO mg of cocaine 15-'1ears­ ago, for which he says he complied with the requirements. However, client thinks that must be why ICE detained him at his house. Client says that he has been taking methadone daily since 1991 with his most recent use five-days-ergo at 150 mg/day/one daily dose. Client is in active withdrawal at present and complained of chills (asked for blanket and one was taken from his cell for his use during th.is session), chills, nausea and stomach pain, headache body aches. Client says medical staff is monitoring his vitals as welt. Client stated that he could concentrate well enough to complete this evaluation, and indeed, he did. He answered questions logically and cooperatlvely. However, he was ready to return to his cell immediately when interview was over. He declined any mental health reading material to take with him. A: Orrented X's 4. No signs of psychosis and no reports of delusions or •· hallucinations as part of withdrawal. DX: Opiate Addiction. Any other OX deferred at present. P: 1) Remain in medical unit as client undergoes withdrawal and medical staff.· 1continues to monitor vitats. , ,,, 2) RTC one we b)(6);(b)(7)(C) assess for any p opiate addictio I> .' . .. b)(6);(b)(7)(C) '"• •, .. ··� •.- t r�' - ... .. . ,. ,,.,,·202o=rctt-oooos-1ss.!.,_:.•.•_. --- _.....,_..,...., � '<:J[,"i.' ·�---�l NT, Inmate/detainee/resident /R)Name: Facility Name: 'What is today's date? · Wliat1s What is your name? Yes I. Have you ever been hospitalized for an emotional or nervous problem? If yes, what hospital? When? 2. Have you ever received counseling or outpatient mental health treatment for the above? o Ifyes, when? Where? 3. Are you talcing any medication for a nervous condition? Yes No Ifyes, name ofmedication/dosage ------1 How often? Who rescribed it? 4. Do you use any of the following: Beer? How much? How often? HowJon ? Howton Wine? OU been takin it? Liquor? o Ifyes, when was the last time? ---------i Have you ever th.ought about suicide? Yes Do you think of it often? Sometim . Seldom? o If yes, when was the last time? __----i Have you ever hurt yourselfwithout wantit!g to {, ,·� Were you in any special education·classes? Are you able to read and write English? Have you ever been convicted ofa viol come, domestic violence, or sexual abuse? Ifyes, When? Where? What crime? , What was ntence? violence, or sexual abuse? 18. Have you ever been a victim of a violent crime, domestic ' · . Where _ If es, When? ? , 19. Do people consider you a violent person? Yes No Ifyes, why? 13. 14. 15. 16, 17. 20. Do you have a history of sexual aggression or sexual assault? Yes Have ou ever been convicted of a sexual offense? 21. How do you feel about your incarceration? □ D . , � · 16 , tr-�-� Zor·o.. .. I -♦'�� ' Referral: �;/ Mental health �fl tf11 e,t!. Physician �k> D Next sick call _ ... □ . Where? Jfyes, When? en? Where? General populati�n er ,b;r.,�t,'r t<5>;< 7> Watch after suicide attempt. Pt states he is "stressed" and depressed. .L � - ....... I ¥WU� •·: ..�flt to--oie-eAd-not-be-Aere-aeeause of. ,, & •·-···--high doses x 28 yrs." Psychoeducation_provided about mood symptoms to be expected while going through w/d. Discussed that he -- will feel better with time: No psychos;_,. -- - 11/30/17 11am ...... -. .. MSE: A&O x 3 Soeech - incoherent Mood -"stressed" Affect - labi!� TP/TC - L/G/GD, no HI/AVH but has passive +SI, no plan or intent, I & . - - . " - 1-1uu1 ...�... Assessment: Opiod Withdrawal, Opiod Use Disorder -. .. Plan: . 1) Continue Su1c1de Level IL --.kb)(6); (b)(7)(C) ')\' __ ..., r ·U -, f"--•;nue 3) RTC 1 day. -·- -/v� I �- 11 b)(6);(b)(7)(C) \?-IO ( / 'Jv I f1:olt1 -� �b)(6);�/7)(�t 1 Tli, - ---In-•- ...,_,_,,1 11 /')0/.17. -- ·- --· (b)(6);(b)(7)(C) GL 2020-ICLl-00006 168 Telepsycn101ns1 GEO Aurora Detention Suicide Alert - LEVEL 2 The GEO Group, Inc. Inmate Name: Location: Stimim,·7 ;ca,,,'4!�----lnmarel\•umbt.:r: ____ 2_Z1_ d- Race/Ethnicity: � Sex: 32 'f'JJ' M Duration of Altrt SPECIAL INSTRUCTIONS: � kJMM. knJ.it f� �1 � ��•,,_, m�I fA.N-.J.. ·�. Shvw-«, Ju� �1,A•h,b µ,:t �� .J'p 11 rJ:-, Ma, � c; � u.,v' f.av,._ I >"1.A'c,,,' � No J,�� ·�cJ:a. 'h. 19',.A.� ,.,u_,hc..L LEVEL 2 CLOSE OBSERVATION INMATE WILL BE PLACED ON SUICIDE ALERT INMATE REQUIRES CLOSE OBSERVATION: DIRECT OBSERVA'fION OF INMATE NO LESS THAN EVERY 15 MINUTES. (b)(6);(b)(7)(C) SIGNED: ..__.________. __ DATE:__ !!.}_"!o It_'!_ . _!/_!!�!..@m1 TIME: _ (b)(6);(b)(7)(C) GEO Aurora e /Health Service Slaff LG-209 Rev:4/10 2020-ICLl-00006 169 Thl' GlO Group Inc INITIAL PSYCHIATRIC EVALUATION Inmate/Detainee/Resident (l/D/R) Name: Samimi, Kamyar I/DIR#: 22732918 Date: 11/29/2017 DOB: 01/03/1953 Facility Name: Aurora Allergies: NKDA 1100 Time:------------ Medications: J • Ativan 1mg IM TIO PRN• not received in 3 days 4. Clonidine 0.1m g PO TIO PRN • taking all 2. Phenergan 25 mg PO TIO takign all 3. Cyclobenzaprine 0.1 g r_o N 5. _lb_u_a_oo _m _ __ , _P_R ______ __ 6. _ _ _ mg PO T1D. _ __ ______ __ S: Reason for Referral (1/D/R's self-reported presenting problem) : Tl•s is a 64 y/o M in Methadone w/d x 11 days now recently placed on suoade precaubons after he was found trying to strangle himself wrth a bedsheel He Cleat1y stated after emergency team responded that what he would like was medication for sleep. Last BP on CIWA 125/85, HR 71. CIWA score consistently Increasing over time. Pt has been noted to have tremors and to be requesting 'stronger medication' frequently. Typical methadone w/d is charac1erized 1/0/R Seen Via{Z]rete-MedicineOace to FaceQell-Side Chart Reviewed?0es0o Psychiatric History (inpatient/outpatient including past medications tried and failed): 1s starting 30 hours after last use and usualy startJng to improve after 10 days. tasting 2-3 weekS. Pt repo,ts dose of 150 mg PO Oday x 2S years. In severe cases Protracted anxiety, depression and fatigue can last for months. It is generally not life threatening although dehydration can occu r. Common treatment includes ant�nausea meds. lmmodtum. Tylenol, hydroxyzine for anxiety. Trazodone as needed fo, sleep Was Univers�y of Colorado methadone And use of an opiate w/d scale and protocol that uses a clonidine taper. Will try to get the opiate w/d protocol form DH. which is d11ferent than alcohol w/d protocol. Can't sleep, vomiting constantly, sweating, shaking, no yawning, + tears, + diarrhea. Denies current SI. Pertinent Medical History: (Head Injury/Seizure) w/d, h/o chronic pain Substance Abuse History: + history of cocaine and methadone. THC Pertinent Personal/Family History (inmate/detainee/residents sentence): Family psych- denies, Family substance• denies, Family suicide- mat uncle killed himself with pills. Family medical denies Institutional Adjustment (current placement): Poorly· in w/d SuicideNiolence Risk Assessment: re Past Suicidal Ideation/Attempts (dates and methods): _x_1_h_e_ _ ____ __________ _ --------------------------Denies Current Suicidal Ideation and Behavior: Past Violent/Assaultive Behavior: _D_ en_ ie _ _ _s _ _____________ ___ _ ___ _ Current Violent/Assaultive Ideas/Behavior: Past Self Injurious Behavior: Rev 2/15 Denies _ s_ _D_ e_n ie _ ____ _________ ____ ___ Page 1 of 2 2020-ICLl-00006 170 IIS 906 fhl' GEO Group. ln< Inmate/Detainee/Resident (I/DIR) Name: Samimi, Kamyar 0: Orientation II} Person Place Ill Time Ill Situation Ill Rapport Dramatic Ill 0 0 0 0 0 Appropriate 0 Goal 0 Delusional 0 Persecution Appropriate Hostile Evasive Distant Inattentive Poor Eye Contact 0 Insight: Excellent 0 Good 0 Fair 0 Poor 0 Grossly Impaired D A: 0 0 Ill Ill Ii] Ill n Compulsions Reference Judgment: Excellent Good Fair 0 Poor 0 Grossly lmoaired D 0 0 22732918 DOB: 01/03/1953 Appearance Appropriately Dressed Appropriately Groomed Poorly Dressed Poorly Groomed Disheveled Body Odor Mood U Euthymic Depressed Anxious Angry Irritable Elated 0 Iii 0 Iii 0 U 0 Phobias O Suicidal Ideation D 0 0 Suicidal Plan 0 Homicidal Ideation □ D D Homicidal Plan Aurora Affect Dramatic U Appropriate 0 Depressed Ill Expansive 0 Blunted 0 Flat 0 Labile Hopelessness Worthlessness Loneliness Guilt Self-Depreciation Th 0021h t Content & Process: Cognitive: No Gross Cognitive Concentration Problems 0 Concrete 0 Abstract n Easily Distracted O 0 Allergies: Facility Name: ,1ective F.ID d.ID2S/MentaIStatus E xam: Ob. 0 Thought Insertion D Broadcasting D Grandiose D Obsessions 0 I/DIR#: Psycho motor Activity: D Normal 0 Restless 0 Retardation 0 D 0 Speech Coherent Appropriate Incoherent Loose Associations Circumstantial 0 Tangential D Poverty Ill Ill 0 0 0 Hallucinations 0 Memory: Immediate Recent Past Pressured Loud Soft Perseveration Clanging 0 Word Salad D Mute 0 0 0 0 0 0 Auditory 0 Visual 0 Command Fair Good Impaired D D D D D D D □ □ DSM-5 Diagnosis: ______________________ P: Plan: (including Rx, target symptoms, labs and special housing) ,,..Push fluids x 15 days, DIC Ativan, clonidine 0.1 mg PO TIO x 4 days �Then clonidine 0.1 mg PO BiD x 4 days, Then 0.1 mg PO QHS x 4 days. Then stop. ,ti-":;\' tJp\1· :; cf\ QC (b)(6);(b)(7)(C) 0 �Hydroxyzine 50 mg PO TIO PRN anxiety x -15 days. lmmodium 2mg Po After each loose stool. TDD JE 16 mg. � $ )..-,.S '""' !:, = �(b-)(6-);-(b-)(7)(C) l �Trazodone 100mg Po OHS PRN sleep x 15 days.. Then decrease to 50 mg PO QHS x 15 days. � Then stop. Offer ensure w each meal x 7 days. COWS mo nitoring x 10 days. Suicide level 2. 1___ Days Psychiatric Follow-Up within: _ Month(s) Recommend referral to Psychologist, Social Worker, or Mental Health Counselor for counseling or No psychotherapy . E: 0 Discussed symptoms of mental illness being treated and frequency of follow-up. 0 Discussed medications being prescribed and potential side effects. IZI Medication consent form(s) reviewed and signed by I/D/ 6)(6),..,..(b)(7)(c )----------. 0 Explained how to access mental health services routinel � .,..,,,.... r b)(6);(b)(7)(C) Rev 2/15 1 Clinician Name (Stamp): Page 2 of2 2020-ICLl-00006 171 ..,.,=""',.,.. Clinician Signature HS 906 (.,, ======� r·� (- ..., .....,.. . REFUSAL OF HEALTH SERVICES Inmate/Detainee/Resident (]/D/R) Name: Date of Birth: ..QL / _ili; 2x:un,m 63 Oat,: I bOf'Ct'>KJr11DIR #: 22, 321 \ i lL;3D1U Time D�1'25�;: K\)J{T)(t,\ _._ l, ________________,Jundertbe careo f the __.._ __......_......_ ____ FacfJity Name 1/D/R Name s and GEO fr�m respon1lb0Jty and le,aJ llabWty formedical services I am r�lease tbe •��nding p bytcf-.n refusing. I am REFUSING to accept the foUowillg treatment plan: Stay in facility's Infirmary or Medical Observation Area: A Diagnostic testing (specify): lv\e._d \ c_a,l {,_:_) 3. History and Physical including lab tests: 4. Medical/Dental/Mental healthcare- (specify): S. Food (specify): 6. Caloric liquids (specify): 7. Sick call: 8. Surgical intervention (specify): 9. Medication (one dose) (specify): 10. Medication (all future doses) (specify): 1 I. Clinician services (specify): 12. IIlV TEST, TB TEST, RPR test (circle appropriate used test): 13. Services in a hospital Emergency Room: 14. Services in an inpatient hospital: IS. Medical trip to a consultant: Reviewing Clinician's Signatw:e/Stamp and Date Jtev6/IO, 6/11. 7/11, 10/12.0111),2/JS ( HS-172 \, .. . 2020-ICU-00006 172 PROGRESS NOTES Inmate/Detainee/Resident (1/D/R) Name: YY\l(n I ,'\(Yl Ail_ Facillcy Name: 1/D/R #: 27-7� I '"-6 Aurora Detention Center Date/11me zv HS-166 Rev I/OS, J/13, I/JS 2020-ICLl-00006 173 see Suicide Alert - LEVEL 2 The GEO Group, Inc. lnmate Name: Samimi, Kamyar _Inmate Number: 22732918 Location:________Race/Ethnicity::,_: _______ Sex: =M__ 24 hours Duration of AJert: SPECIAL INSTRUCTIONS: I May have toilet paper, May have shower, soap and comb, toothbrush underwear OK, May have regular diet and spork, May have reading material, May have geo uniform. Suicide mattress and pillow. LEVEL 2 CLOSE OBSERVATION INMATE WILL BE PLACED ON SUICIDE ALERT INMATE REQUIRES CLOSE OBSERVATION: DIRECT OBSERVATION OF INMATE NO LESS THAN EVERY 15 MINUTES. b)(6);(b)(7)(C) SIGNED:_ DATE: SIGW' DATE: b)(6);(b)(7)(C) Service Staff 11/29/2017 ,i1 \( f I I TIME: 1104 am/pm TIME: am/pm I I/ I Rev: 4/11 �; {9_ ;fJYVl rr-- _. LG-209 2020-ICLl-00006 174 _ _J ( Attachment C Suicide Alert - PENDING The GEO Group, Inc. Inmate/Detainee/Resident (1/D/R) Name: Location: SCt rY) ,- IV\ � I Inmate/Detainee/Resident (1/D/R) Number: !J � =t-3?...Cf I � kaM.�r-- ,� I Race/Ethnicitv: I Sex: TV\ SPECIAL INSTRUCTIONS ,. t b(A_; d.,L fi'\A C. • 0. O t,...) nc!�f � .-- 1 D S h..ub i,-f") &f VIY'fi...t.' fn,d.s � V\.. c' C.,c' 1 Ld- -- k.,1� M."""' t-t-c,-,.- ,� de. LLc..n.� pc. p u {-::, 7 � -t- o ri I 1 I I h L,,...1' S""-Gv{ l l (-� l?vo � CH co._.,.,.._ I R,'bLL­ �p-.e r- Gpoi::)rt I/DIR WILL BE PLACED ON SUICIDE ALERT-PEN:DING LEVEL 1 - PENDING 1/D/R REQUIRES ONE-ON-ONE SUPERVISION Staff member within fifteen (15) feet of 1/D/R )(6);(b)(7)(C) 1gnature Date Time Print Name and Signature Date: Time Health Services Print Name and Signature Date: Time Print Name an This form will be placed in the medical record. After immediate verbal notification of .Placement on Suicide Level 1 status a co� of this form ,viii be distributed as follows: The Facility Warden, The Assistant Warden of Security, and The Chief of Security/Designee. 2020-ICLl-00006 175 CONSENT FOR MENTAL HEALTH SERVICES 5,.,.,.,:""' � 1 The GEO Group, Inc. KA.-.. rif/ t-'2?:321, g" TO THE PATIENT: You have the right, as a patient, to be infonned about your mental and physical condition, the recommended mental and physical procedures to be used for finding out about your problems, and the benefits, risks and hazards involved in the treatment provided to you by the staff at this unit. This disclosure and consent form is not meant to scare or alarm you, but is simply a method to better inform you about your recommended treatment. TREATMENT BY MEDICATION: Treatment with psychiatric medications will be based on decisions made by a doctor. The method of giving the drugs and the amount of drugs will be monitored by the treating doctor. You will be infonned by the doctor or his/her assistants of the following: I. The expected results of the medicines and the side effects, hazards, and risks involved with taking those medicines 2. The benefit or good effects that you will receive from taking the medications 3. Treatment with these kinds of medications may be forced on you if two doctors agree that you are a danger to yourself or others, or that you are unable to care for your basic needs. TREATMENT BY COUNSELING: A treatment plan will be developed by your treatment team under your doctor's guidance. Your treatment plan will consist of treatment therapies, recommended by your treatment team, to help your current mental condition. You will by assigned a mental health professional who will inform you of the following: 1. The different treatment programs that have been recommended for you (such as talk groups, on-to-one counseling, etc.) 2. The good effects of active participation 3. The hazards and risks involved You have the right to refuse all of your treatment with the exception of Item 3 in the "Treatment by Medication" paragraph. LIMITS OF CONFIDENTIALITY: The contents of a counseling, interview, or assessment session are considered confidential. Both verbal information and written records about you cannot be shared with another party without your written consent or the written consent of your legal guardian. Exceptions to these limits of confidentiality are as follows: 1. When you disclose intentions or a plan to harm yourself or another person, or to participate in activity which may jeopardize the safety of the facility, the clinician is required by law to report this infonnation to the appropriate authorities. 2. If you state or suggest that a child or vulnerable adult is in danger of abuse, the clinician is required to report this information to the appropriate authorities. 3. In the event of your death, your spouse or parents may have a right to access your health records after the proper paperwork is submitted in accordance with policies and procedures. 4. The GEO Group, Inc. is required to release your records if a court orders the release of your records. 5. Information about you may be disclosed to other healthcare professionals to provide you the best possible treatment. 6. Other Health Services staff have access to the information contained in your health records. 7. The Warden/designee may have access to your health records in the event of a legitimate need. 8. Contracting jurisdictional officials and their designees have access to your health records in the event of a legitimate need. Rev 6/14 I of2 2020-ICLl-00006 176 HS 121.1 CONSENT FOR MENTAL HEALTH SERVICES (Co111i11ued) The GEO Group, Inc. I CERTIFY THIS FORM HAS BEEN FULL\' EXPLAINED TO ME, THAT I HAVE READ IT, OR HAD IT READ TO ME, AND THAT I UNDERSTAND ITS COJ\TENTS. INMATE/DETA EE/RESII;>ENTi.WD/R) PRINTED NAME: . (b)(6);(b)(7)(C) I\� f'tA / 1/D/R SIGNA DATE/TIME: __l_lfl_i>__________ ---'-/'-',/._$_"....,!)_, � I CERTIFY THAT I HAVE REVIEWED THE BENEFITS AND RISKS OF TREATME!\"T IDENTIFIED ABOVE, WITH THE I/DIR. HEALTHCARE PRO PRINTED NAME: (Cl SIGNATURE/STAMP: 1/D/R UNABLE/UNWILLING TO SIGN WITNESS: ______________________________ PRINTED NAME: ___________ _________________ DATE/flME: _ ____ SIGNATURE/STAMP: ______________ llS 121 1 Rev6114 2020-ICLl-00006 177 Geo 1,r. CONSENT TO USE OF HYDROXYZINE . ID No. z_z 1.3 Z CJ I_L _ _ hereby authorize Dr._ • t I l/h�� \,� or his/her relief (designee). to prescribe hydro�:yzine (Vistaryl)1 an antianxiety medication. to me and to contirml· !'.aid medication as is recommended for my psychiatric treatment. I. This medication is useful because it has been found to be effective in assisting with the management of an.xicl� di,ordcrs and rhl'ir associated symptoms including. but not limited to. restlessness. irritability. and sleep disorder. 2. This medication may improve your condition by relieving all or some of the symptoms mcntinncd aboH' 11 hcn wl.cn a, prc,crihcd The medical staff cannot guarantee the effectiveness of the medication. a!> responses arc paticnt-spcnfic. 3. Common side effects to this medication may include. but are not limited to. drowsinc�s. nau�ca. cxcitcrncn1. di, 1incss llr lightheadedness, headache. tiredness, or nervousness. These effects are frequently temporary or can he controlled with a drnngc in dosage. If any of the above symptoms occur, you should notify the Health Services stafT as soon as possible. 4. Alternative treatments may not include any medication, but may involve counseling by a psychologist or other medical profc��i1 1nal Based upon interview. assessment. and medical record review. it is my opinion that this patient is !!fil com1,etent 10 gi\'c con:.cnt. Physician Signat\lrc ___________________ -- Other issues discussed The patient certifies that he/she has read the foregoing, or has had it explained in a language they understand. hcrcb> con�l·nt> IV treatment and has no additional questions. Linc 1-4 above have been explained to the patient and based upon inter. iC\\. a,scssnu.:111. and medical review, it is the opinion that this patient understands the proposed treatment. and is competent to give cC1nscn1. The palil·nt ma� stop taking this medication at any time by contacting the physician: ho,\ever, discontinuing the medication abniptl� is g.cncrnll� n1.11 advisable. J/ b)(6);(b)(7)(C) Dale ID/R Number - F ,,.,..., Z-Z 13-Z 11 '5 A-va>R" [)arc IJ)t.ll }tJ' 11 Atten(b)(6);(b){7)(C) /U/,J Dote ''/t.A/11 Nami '-- HS-IQ0,10 New 8/14 2020-ICLl-00006 178 ·- I I ( ...,c:1.u.u.uu, J'-.cuuye:u· vv�voot..Jt.�J rnn1eo 0�1..b_J<_6_J; _b _J<7 _l_L'+J 0 D When• 09/18/1998 � b f _l<_6J_;<_b l_<7_Jc_cJ_ ________________ L Page 2 of2 Type \Mth Description Historical Outpatient Encounter Psychiatry - Provider, H Opioid type dependence, abuse (b ( -----�liJ/29/2017 =00006 �8tt 100 0006rf8&--ICLl-0 -----------z6:2 2020) .Ll -)(7-) E- - ..;)(llllUlll, l\..e:tlllyac lJVlKffVOO.L.).L'¼) 7 rnmea oyf._b_)<6 _J;_;( bl_( 7 _> c< _> _____.Ion/at 12/1/2017 11 :24:23 _ L Print Nameand Signature Date Time Time ignature Oater I Time the medical record. After immediate verbal notification of placement on L_.......,.......,.e:-,-;;e:uve�-;;s.,;ta�tu:::s:-:a:--::c:::opyof this form will be distributed as follows: The Facility Warden, The Assistant Warden of Security, and The Chief of Security/Designee. Su1c1de Al�n • l.e••�/ I Fon11 t IIS-2117 J New /1/J R�: 0511017 2020-ICU-00006 188 PROGRESS NOTES Inmate/Detainee/Resident (1/D/R) Name: I/DIR #: Date/Time l \ Rev J/OS, 1/13, J/IS \ \ 2020-ICLl-00006 189 DOB: ee e...... Facility Name: Aurora Detention Center =acility Name _::i- oet ,,.... � Z� Po .-.f-\cr f""'\ - =� J .S� oo �NI����?) l HOUR � START DATE I• ...,�4ZD�o.t\L /DO I go), 7 ('o ") ),1 ro 51:?j ffelni��?C6);(b)(7)( I START DATE 1,z...} l'f /11 STOP DATE IZ--) Q� �),7 CD 0 S. IN -"-1. d-,v M � ....�,: J' 10 'Z' frz_/ STOP DATE 13--)� Q t±S ),1 5 6 7 8 Month/Year IP-})� 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 3· t/ STOP DATE START DATE STOP DATE N lnit. START DATE STOP DATE N lnil. START DATE STOP DATE " lnit. START DATE STOP DATE -- ....-- r.:;- L--' V ;l!,,t -z-/'Z-8')17 ,, Inc. f ,:::,;;,_ .....,.:..+-�col--.. ...,,.., :N lnit. ;1/'J<()/.J 4 / f,2././ STOP DATE l NAre.-r::A-,'-c. 5 lni�(b)( );(b)(?)(C) �ART DATEIJ }z_. 4 LERGY 3 \...- 1..- .... ,. 2 eA 0 f.... {?0:4 -e,r-r� /b'j -,...._ Z..}' �b)(5);(b)( ?)(C) START DATE 11 / V1 /(" � Z, 6 ,./,:>,A t:_ 1 / / - / , rY, t,z,,)g-Jr7 NURSE'S SIGNATURE - INITIAL NURSE'S SIGNATURE I .GNOSIS :>CUMENTATION CODES = ::: • Discontinued Order ) • Dose Omitted · Medical Hold R • Refused C • Court LO • Lock Down S • Self Administered NS· No Show O • Other 2020-IC 1-00006 �®OIMACY SUGGESTIONS/RECOMMENDATIONS DO NOT SUPERCEDE PHYSICIAN ORnFR� INITIAL i Progress Notes Inmate#: Inmate Name: Samimi, Kamyar A22732918 DOB: 1/3/1953 Facility Name: Aurora Detention Center ... . ... l1- Date: Comments: O; wi therapist told client when he was upright in the hall being supported by two labs look good. He's had a few good days. Other than some thyroid that we will need to supplement, his labs look good." P: 1) Remain in medical unit as client undergoes withdrawal and medical staff continues to monitor vitals. b)(B);(b)(?)(C) 2) RTC when client stable enough to have a coherent conversation client is able to engage and understand and comprehend the conte (b)(6);(b)(7)(C) I t' I ·• f RECHAZO DE SERVICIOS MEDICOS N o mbre del recluso: Numero del recluso: ,see .............. □ □ AM Hora: PM Fecha: __ / __ / __ Yo, __________________, bajo el caldado de_____________ Nombre del reduso • Nombre del centro DesUndo de obligac16n y de responsabWdad legal al mMico tratante y a la compaiifa GEO por Jos serviclos medicos que estoy rehusando. Estoy REHUSANDO aceptar el plan de tratamlento slguiente: Fecha de nacimiento: __ / __ / __ I . Permanecer en Ja enfermeria o area de observaci6n medica de) centro: 2. Examenes de diagn6stico (especifique): 3. Historia y examen fisico incluyendo anaJisis de Iaboratorio: 4. Atenci6n medica- (especifique): 5. Comida (especifique): 6. Liquidos caloricos (especifique) 7. Atenci6n amdica de urgencia: 8. Intervenci6n quirurgica (especifique) 9. Medicamento (una dosis) (especifique): IO. Medicamento (todas las dosis futuras) (especifique): 11. Servicios clinicos (especifique): 12. Analisis de VDI. A.nalisis de TB, Analisis de RPR. (encerrar en un circulo el analisis adecuado que se uso): 13. Servicios en la sala de urgencias de un hospital: 14. Servicios intemos en un hospital: 15. Viaje medico a un consultante: ***Profesional med o:. Escriba que tr tamiento o ed .y- Se me ha info o acerca de Ios riesgos involucrados en el rechazo del tratamiento o examen indicado mas aniba y por el presente libero aJ medico tratante y a GEO de TODA RESPONSABILIDAD por los efectos adversos que rcsulten de dicho rechaz.o. Finna del recluso Fecha Firma del testigo (Empleado de la compaftfa GEO) Fecha Testigo # 2 si el recluso rehusa finnar Fecha Firma y sello del profesional medico Fecha Finna y sello del medico supervisor Fecha Rev 6/10, 6111, 7/11, 10/12 HS-172-SP 2020-ICLl-00006 192 r Section 11- Mental Health Mental Progress Notes Mental Health Evaluation Individual Treatment Plan Psychiatric Evaluation PREA Risk Assessment Medication List Abnormal Involuntary Movement Scale (AIMS) Therapeutic Seclusion and Restraint Nursing Flowsheet Suicide Alert Forms Consent to Medical Health Services 2020-ICLl-00006 193 HS-166 HS-158 HS-906 HS-102 HS-182 LG-207,208,209,211 HS 121.1 Section 111- Dental Dental Dental Dental Dental Health Record (2 pages) Progress Notes X-Rays refusal forms, consent forms and request forms 2020-ICLl-00006 194 HS-124 HS-166 Ge@ Tho, GEO Group, Inc. HEALTH SERVICES - DENTAL HEALTH RECORD SUBSEQUENT EXAMINATION A22732918 SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: !JUI K � tt. Nation: IRAN Date: ne: 11/ 17/2 017 16:00 ----------- Date of Birth: --- --- I --- / ___ I Facility Name: Aurora ICE Processing Center Has a doctor ever told you that OU have: Heart Problems I. Y N Dental/Medical History Y N 6. Artificial Joints/Valves y 11. Asthma/Respiratory Problems 2. Heart murmur 7. Rheumatic Fever 12. Allergic to Medications 3. High Blood Pressure 8. Hepatitis/Liver Disease 4. 13. Taking Medications Diabetes 9. Uncontrolled Bleeding 14. (Women) Pregnant 5. Epilepsy I 0. Stomach Ulcers IS. Other DISEASES & ABNORMALITIES (complete in pencil) RESTORATION AND TREATMENT (complete in ink) Occlusion Oral Hygiene (circle one) Good CPITN D D Head & Neck/Soft tissue: Additional Findings D: M: F: Examiner Signature and Stamp: D D D D Fair Poor □ Date: CPITN: CLINICAL PERIODONTAL INDEX OF THERAPEUTIC NEEDS Rev 6/14 Page Recommended Treatment Plan Radiographs: Dental Prophylaxis: Oral Hygiene Instruction: Periodontal Evaluation: 0 III I II Oral Surgical Procedures: Endodontic: Restorative: Prosthodontic Evaluation: Dentist Signature and Stamp: D:DECAYED I ofl 2020-ICLl-00006 195 M:MISSINC Date: F:FILLED HS-124 N ( The GEO Group, Inc. DENTAL HEALTH RECORD (Cont'd) A22732918 SAMIMI, KAM YAR DOB: 1/3/ 1953 Arrival Date: ,jJ -· -- - Nation: IRAN 11/17/2017 16: 00 - #=Tooth No. 1e: Date of Birth: I -- I P = Priority Facility Name: Aurora ICE Processing Center Date/Time Rev 6/14 # SERVICES RENDERED p Dentist (Signature and Stamp) Page 2 of2 HS-124 2020-ICLl-00006 196 ee0 --GIIIIIIJ,IPlc, MEDICAL OBSERVATION NURSING PROGRESS RECORD ( FACILITY: Date/Tim e 11/).Ci It, IJ'77) fiv/e/"'"-. Inmate/Detainee/Resident (J/D/R) Name: ) a M ,'/'1: i /t,'1 M \IC< v s> ..eA- s-V\ ,\A't1,e. IvI n I l ______ _�/V ::....'�LA ALLERGIES: I I/DIR#: '2. l- 7 3 "'2-'1 / b ,-1.,,..,," L'.A-" r ,. • .Vat-.,.r £A 1-1-.. ._J d. IA I DOB: ·l/?/S t7J - 4 fP/vlx, '.,.f-J-, Chest pain: yes /foJf yes, describe: Abdominal pain: �DO Hyes, describe: v7 w---< > CA Other pain: yes/Jlo'Jf yes, describe (Pain scale J-10): Nausea/vomiting:�DO If yes, describe: .rt�f � rr./)p/..fjJ Cough/SOB: yes/ ')Ifyes, describe: Urinary Symptoms: yes l'{io) If yes, describe: BP: / 11�/ 62- 02 Sat: 100 Weight: ft/IA 0) T: '1'7 , P: 11.-0 R: I l, _ Speech slurred: ,Jcj,)no Alert & Oriented x 3: '(y� I no If no, describe: Skin : Normal/pale/f1iishedl/ jaundiced/diaphoretic Skin tempenture (Cold, hot, wann, Heart (RRR. ifno describe): -i-11-� Oxygen use: yes I(60 Uyes, amouot: Lung sounds (bilaterally): IA� no ✓ - - Abdomen: Normal: i"e)/no If no, descn1>e: Last BM: II/ 2. 7// / Bowel sounds: yfs.Jno Descn'bc ifabnormal ' Last stool (Color, consistency): Nmmal. Ifnot, describe: ,r q� /" Incontinence ofurine: yes (no;J Foley: yes {no) Self-void:{.n,1 no Wound type: ,91' Dressing type (descn1>e): Size (in cm): Location ofwound: r-o/ Signs ofInfection: yes /niJ-,lf yes, descn'bc: Drainage (amtJcolor): ef Hand/Arm strength (lfapp'Jicable): Equal: ffe,/no lfno descn1>e: I A • Leg strength (If applicable): Equal: yes /no If no, describe: ✓ - , Edema: yes/¥0) Pedal pulses (If applicable): Equal: yes/no Ifno, descn1>e: IV location: Type/Rate ofIV solution (ifapplicable): # ofhours at cwrent JV site (not> 72 hows): Condition of IV site: Hun.gee Strike: yes .{no")lfyes, complete next 2 rows. Room checked for food by security? yes /� ls I/DIR drinking H20? yes/no Ifno, when was the last H20 consumed?: Amt: Time: Type: Last caloric intake: Date: --�ce 7 t C7 l A I /11-r Comments: l).JJ.% vvl ,1 A: ti_� clt'"ti\, h\sv1 P+E: W .'\ I e-o,vh'MA..(_ ,,.,..,JI�'4,JI<9V'\.( \A �e.. ; ,A,. £,t,11u.,-,.J·-r h, /VW r'\. • �).,. NURSE'S SIGNATURE/STAMP AND DATE_ l r..<11/0,i', ;r\tr-1 [,.J' .r b)(6);(b)(7)(C) LqlAI{> HS-142.6 �ll, 5 /JJ, 1113,6/14,2/15 2020-ICLl-00006 197 The GEO Group, Inc, ALCOHOL WITHDRAWAL ASSESSMENT AND TREATMENT FLOWSHEET Assessment Protocol a. Assess vitals and CIWA-Ar. b. If total CIWA-Ar score �8, repeat every hour. Once the CIWA-Ar score< 8, then repeat every 4--8 hours until score has remained < 8 for 24 hours. c. If initial Total CIWA-Ar score < 8, repeal CIWA every 4--8 for 24 hours. d. If indicated, administer PRN medications per GEO protocol. .t, . ., , . , Date 1, IN. t l'JQ n nb nme ,u.,... Pulse RR Oa sat BP 4 � 1.. < IL lV � i; 0 .,4/ i � B\) ¥?if l()\)t /., Nausea/Vomiting: Rate on scala of�7. Tremors: Have patient e/dend arms and spread fingers. Rate on scale of �7. 0 0 - no tremor; 1 - not visible, but can be felt fingertip.to-fingertip; 4- moderate wi1h anns extended; 7. severe, even with anns not extended Anxiety: Rate on scale of �7 . 0 - none, at ease; 1 - mildly anxious; 4 - moderately anxious or guarded, so anxiety is Inferred; 7 • equivalent lo acute panic stales, as In severe delirium or acute schizophrenic reactions 0 0 - nonnal activity: 1 - somewhat normal activity; 4 - moderately fidgety and restless; 7 - constantly paces or thrashes about 0 0 - no sweats; 1 - barely perceptible sweating, palms moist; 4 - beads of sweat obvious on forehead; 7 - drenching sweats 4 0 - orienled; 1 - caMot do serial additions, uncertain about date; 2 - disoriented to dale by no more than 2 days; 3 - disoriented to date by> 2 days; 4 - disoriented to place and/or person Agitation: Rate on scale of �7. Paroxysmal Sweats: Rate on scale of�7. Orientation & Clouding of Sensor/um: Ask, "What day is this? Where are you? Who am I?" Rate on scale of 0-4. Tactile Disturbances: Ask, "Have you experienced any itching, pins and needles sensation, burning or numbness, or feeling of bugs crawling on or undar yourslcin?' Rate on scale of�7. <\bi \2J/q-,, 125/� y 4 4 0 - none; 1 - very mild ttch, P&N, burning, numbness; 2 - mid itch, P&N, burning, numbness; 3 - moderate itch, P&N, burning, numbness; 4 • moderate halluc.'lations; 5 - severe hallucinations; 6. extremely severe hallucinations; 7 • continuous hallucinations Auditory Disturbances: Ask, •Are you more eware of sounds around you? A,e they harsh? Do they startle you? Do you haar anything that disturbs you or that you know isnY there?' Rate on scale of �7. O - not present; 1 - very mild harshness or ability to startle; 2 • mild harshness or ability to startle; 3 - moderate harshness o r abiHty lo startle; 4 - moderate hallucinations: 5 - severe halucinations; 6 • extremely severe hallucinations; 7 - conlinUOU$ hallucinations Visual Disturbances: Ask, "Does the light appear to be too bright? Is its color different than normal? Does it hurl your eyes? Ate you seeing anything that disturbs you orthat you know isnY there?" Rate on scale of �7. 0 - not present; 1 - very mUd sensitivity; 2 - mild sensttivity; 3 - moderate '8nsllivity, 4 - moderate hallucinations; 5 • severe hallucinations; 6 • extremely severe hallucinations; 7 - continuous ha!ucinations Headache: Ask, •0oes your head feel different than usual? Does it fee/like there is a band around your head?" Raia on sea/a of�7. Do not rate dizziness or lightheadedness. 0- not present; 1 • very mild; 2 - mild: 3. moderate; 4. moderately severe; 5 - severe; 6 - very severe; 7 - extremely severe .,-.,.»:.;·.,�·: ,.:-;, 1 1 -����· ,� y L 7 D I 0 0 0 D 0 0 0 1) 0 0 a �'i;;i '1 fA't. Lb 'jl!e1t�;ilitYo.UOW11>q1Jli!iili?:.�;.t•::'1i!,\,:ffi·�r,_>.tf,,,Jf.�\(.;',.rl��,:t;�i\i;,� �-f,_;;�;:,_;:� �)i-,'•'.•¥,:;:l>7i4'.:ltf-k -�;,·. 0 - none; 1 - mild nausea, no vomiting; 4 - intenniltent nausea; 7 - constant nausea, fr...,uenl drv heaves and vomillno -: &, I 0 0 3 b =--��a,,;���� t'.:{!f-i_'.ift:,�, �ti tr;;,··..\�� �\�-�� :P7• [J D [) 0 D 0 •;�'�m,�.1-. :,f;� t:��11-� }i�.�\:'�.r- .}., 1 f' ,;_,-,:,�� ��� ,�Jd.: �(.)";&��. ;:1•/:·:°f-' Indications for PRN Medication: Please follow the protocol in GEO Clinical Practice Guidelin�for Detoxif,cation of Chemically Dependent VD/Rs for use of lorazepam and other medications for withdrawal. See Table 2 and Section 6 on Alcohol Withdrawal. ".-�.·-·�t_.-- - I-;;... -�..:•:: Medication administered? (see Medication Administration Record) Yes/No: Time of PRN medication administration: Assessment of response: (CIWA•Ar Score 30-60 minutes after medication administered) I Provider initials: 1/D/R Name -=$:..,(UV\.---=-( .:...rn_:._, ._, ..,_l(_a. m_,.:... l ..::. uc.....:... V__ .,,, Reg No . __O.-=--i_t_3-=--�'f....,__._I.,,.'[____ Date of Birth / / � Institution I (b)(6);(b)(7)(C) I I I ... I I Rev 8/14 2020-ICLl-00006 198 HS 104.1 PROGRESS NOTES >""""'. =,'V'J ,r ( DOB: 1/D/R #: �27321/g Inmate/Detainee/Resident (1/D/R) Name: I tu v" r V"t Facility Name: P: \-\-t'. 1· 11�{� I 11 �o /07 'tg,1 1..: '� 95'7o � ct fq,\, S: 001' (n f /fA./1 f <,.J S//�i.k_)/1,ep w. � he,, A�{ .J NO} D: V5 vJNL, f"✓1JO ✓ f, 11111-. I �J.,,/1"(' �w Lre. D� 'h1 A,\ f)-tf CcJ/Vt � �(\� ,/') I < �+ b ,,... ,,,,./Jr!)/ - �� � 1-u l.>t-LA...... 1-,c/Y) '< u �,\�..� h v\C\. \-r, ✓� f � LJ, I l�Ahh v...-t. +o l / ·ff019,r f)/\ £?. I � /"Vl..ui1 -e,wr-t aut,'oviJ I vwb1v(:-z,,� fb)(6);(b)(7)(C) � HS-166 Rev I/OS, 1/13, 1/1 S 2020-ICLl-00006 199 PROGRESS NOTES Inmate/Detainee/Resident (I/DIR) Name: Facility Name: 1/D/R #: Aurora Detention Center Date/Time I( 11...J ' rr{,,(_ res Ntv10Ve.e/ HS-166 Rev 1/05, 1/13, 1/15 2020-ICLl-00006 200 PROGRESS NOTES Inmate/Detainee/Resident (1/D/R) Name: s f1 , 1/D/R #: 277�2 I y DOB: I 3/53 see ....... : Facility Name: Aurora Detention Center Date/Time II HS-166 Rev 1/05, J/13, 1/15 2020-ICLl-00006 201 PROGRESS NOTES Inmate/Detainee/Resident (I/DIR) Name: SPr m IN\ ·1 IL I\ � J/D/R #: 227 DOB: t ?, Facility Name: 03 Aurora Detention Center ?e,:no 3D me, �c) e- /VI qAt- X 3� l.,..l5)�� �'tc,C) L . - lB "-J t , ,.._, � t m 6 t--J '\- d ,'Z. 't.J me cl !- -��-------� HS-166 Rev I/OS, 1/13, I/IS 2020-ICLl-00006 202 11/21/2017 /To: 05:09:00 AM TO: 13033608825 FROM: LABCORP LCLS BLK PAGE 1 of 3 AURORA DETENTION CENTER ICE ILabCorp Patient Report Acct#: 05000045 Specimen ID: 322-U42-0002--0 _,,..,,,.- Control ID: L2105000045 I Patient Details DOB: 01/03/1953 Age(y/m/d}: 064/10/15 Gender: M SSN: Patient ID: Ordered Items Phone: (303) 361-6612 11901 East 30TH AVE Aurora CO 80010 1 I I• 11 lh I 111 1 •II• 1111 1 I• 111 111 1 11 11111 11 1 11 • 1 I111 11 11 111 Ihi' •h Specimen Details Date collected: 11/18/2017 0000 Local Date received: 11/20/2017 Date entered: 11/20/2017 Date reported: 11 /21/2017 0508 ET I Physician Details Ordering: Referring: ID: NPI: CBC With Differential/Platelet; Comp. Metabolic Panel (14 ); Urinalysis, Complete; TSH; Stat Service; Travel Fee TESTS RESULT FLAG UNITS REFERENCE INTERVAL CBC With Differential/Platelet 4.0 - 11.1 10E9/L 6.5 WBC 4.76 - 6.09 10E12L 4.90 RBC Low 14.3 - 18.1 13.9 g/dL Hemoglobin 39:2 - 50.2 44.0 % Hematocrit 8 0.0 - 100.0 8 9.8 fL MCV 27.5 - 35.1 pg 28.4 MCH 32.0 - 36.0 Low 31.6 g/dL MCHC 11. 7 - 14.2 % 13.5 ROW 219 150 - 400 10E9/L Platelets b)(6);(b)(7)(C) 57.4 % Neutrophilf 33.3 % Lymphs 7.4 % Monocytes GEO Aurora Detent1cw % Eos (b)(6);(b)(?)(C) % Basos 1.8 -,6.6 10E9/L Neutrophi 1.0 - 4.8 10E9/L Lymphs (A 0.2 - 0.9 10E9/L Monocytes'm:==:-cri==r---------,,....,.,::r------' 0.0 - 0.4 10E9/L 0.1 Eos (Absolute) 0.0 - 0.2 10E9/L 0.0 Basa (Absolute) % 0.2 Immature Granulocytes 0.00 - 0.05 10E9/L 0.00 Immature Grans (Abs) 0 % NRBC ---------� Comp. Metabolic Panel (14) Glucose, Serum BUN Creatinine, Serum eGFR If NonAfricn Am eGFR If Africn Am Sodium, Serum Dace Issued: 11/21/17 osos ET Rte: SD AURORA DETENTION CENTER ICE SAMIMI, KAMY AZ I LABCORP 111 19 0.8 9 60 60 140 mg/dL mg/dL mg/dL 70 - 199 7 25 0.70 - 1.30 mL/min/1.73sq.m mL/min/l.73sq.m mmol/L FINAL REPORT This document contains private and confidential health information protected by state and federal law. If you have received this document in error, please call 303·792-2600 2020-ICLl-00006 203 LAB 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 133 - 145 01 Page 1 of3 0 1995-2017 Laboratory Corporation of AmericaCO Holdings All Rights Reserved • Fnterprise Ri>port Version: 1.00 p 11/21/2017 05:09:00 AM TO: 13033608825 FROM: LABCORP LCLS BLK PAGE 2 of3 LABCORP Patient Report Patlent:SAMIMI, KAMYAZ / DOB: 01/03/1953 TESTS Spec;imen ID: 322-U42-0002-0 Date c;ollec;ted: ·11/18/2017 0000 Local Control ID: L2105000045 Patient ID: RESULT FLAG UNITS REFERENCE INTERVAL 3.5 - 5.1 mmol/L 4.1 Potassium, Serum 98 - 108 102 mmol/L Chloride, Serum 21 - 31 mmol/L 30 Carbon Dioxide, Total mg/dL 8.6 - 10·.3 9.1 Calcium, Serum g/dL 7.3 6,4 - 8.9 Protein, Total, Serum 3.5 - 5.7 4.3 g/dL Albumin, Serum 0.1 - 1.3 0.4 mg/dL Bilirubin, Total Adult Reference Range 39 - 117 Alkaline Phosphatase, S 110 U/L The adult reference range is (39 - 117 U/L}. During growth through puberty results can be 3 - 4 times greater than in adulthood. 21 U/L 12 - 39 AST (SGOT) 7 - 52 19 U/L ALT (SGPT) Urinalysis, Complete Urinalysis Gross Exam Specific Gravity pH Urine-Color Appearance WBC Esterase Protein Glucose Ketones Occult Blood Bilirubin Urobilinogen,Semi-Qn Nitrite, Urine Microscopic Examination See below: 0-5 WBC None seen RBC Epithelial Cells (non renal) None seen Epithelial Cells (renal) None seen None seen Casts None seen Cast Type None seen Crystals None seen Crystal Type None seen Mucus Threads None seen Bacteria None seen Yeast Dace Issued: 11/21/17 0508 ET 1.001 5.0 1.019 5.0 YELl.iOW CLEAR Negative Negative Negative Negative Negative Negative <2 Negative mg/dL /hpf /hpf b)(6);(b)(7)(C) FINAL REPORT This document contains prisate and confidential health information protected by state and federal law. If you hase receised this document in prror, plPasP call 303-79,-2600 2020-ICLl-00006 204 - 1.035 - 8.0 Clear Negative Negative Negative Negative Negative Negat:i,ve <2 Ne.gative 0 0 5 3. LAB 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 01 Page 2 of3 � 1995-2017 Laboratooy Corporation of America® Holdings All Rights Reser.ed - Fnterprise Report Version: 1.00 p ,,,,,-,- 11/21/2017 05:09:01 AM TO: 13033608825 FROM :LABCORP LCLS BLK LABCORP PAGE 3 of 3 ilabCorp Patient:SAMIMI, KAMYAZ _.,./' OOB:01/03/1953 Patient Report ,. PatientlO: TESTS Trichomonas TSH Specimen ID: 322-U42-0002-0 Date collected: i 1/18/2017 0000 Local Control ID: L2105000045 RESULT None seen FLAG UNITS REFERENCE INTERVAL 01 7.47 High mIU/L 0.34 - 5.60 The reference range for this analyte was changed on 04-10-14, �rom 0 .50-5.0 0 mIU/L to 0.34-5.60 mIU/L, due to a change in methods. Interpretive Data: Testing was performed by Access HYPERsensitivity hTSH (3rd generation). NHANES III data suggests that TSH levels for thyroid disease-free adults are generally between 0.45 and 4.12 mIU/L and are age-dependent. Reference intervals for pregnant patients and neonates have not been validated. 01 9R LAB 01 Dir b)(6);(b)(7)(C) Univer of Co Hosp Auth Cl Lab 12401 E 17th Ave Le rino Bid 1st/2 Aurora CO 80045-3706 For inquiries, the physician may contact Branch: 303-792-2600 Lab: 720-848-7701 NOV 2 7 201v;:J Jeffrey Peterson, M.D. GEO Aurora Detentio11 (J_SJb{'J ' Date Issued: 11/21/17 0508 ET FINAL REPORT This document contains private and confidential health information protected by state and federal law. If you have received this document in error, please rall 303·792-2600 2020-ICLl-00006 205 Page 3 of3 e> 1995-2017 Laboratory Corporation of Americail> Holdings All Rights Re\erved • Fnterprise Report Version: 1.00 p A22732918 SAMlMI, KAMYA R DOB: 1/3/1953 . Arrival Date·. Blood Pressure Record N a t·ron: IR AN 1 1117/2017 16. 00 Ordering Physician: __________ Date of Order: � z.,,,/ 3)C u.J7L Order as written: DATE Inmate Number: TIME ARM BP l \ I 1_5J )�'{�ct 111 �K i I/,�)!,)n l�?-r IG¼ 1\.( -n I 11101 1-} -� s- \''J-/ ''i L W1 5 o.., )01..--wlL My R ✓ l/ l.,...,-' POSfflON (supine, sitting, HEART RATE ,5)M1� $� . J (JJ'], . v standios!:l .s I+ t J::e-k-;Y f F- 1'- SIGNATURE/CREDENTIALS b)(6);(b)(7)(C) !;l\ H\ ! l I Rev 3AIS, 12/l 2, I/J3 ffS.108 2020_1cu-ooooG 206 MEDICAL OBSERVATION NURSING PROGRESS RECORD FACILITY: ------=-f)_vt_�.,,_rc,,._· Inmate/Detainee/Resident (I/D Date/Time 6"'"'1,Nl; I I _______ ALLERGIES: ______________ ) Name: IR /��l\,\�y' S) /1/ll -/1 ,".. d,,, '--"- 11/D ':J..-t,...> 't< ll IR # : )_:). 7 -3 J1 J 8 Chest pain: yes /�9 If yes, describe: Abdominal pain: yes / no Ifyes, describe: Other pain: yes /Q!9,1 If yes, describe (Pain scale J -10): Nausea/vomiting: yes / no Ifyes, describe: 1\,/c,,....,�� Cough/SOB: yes ("Jip) If yes, describe: Urinary Symptoms: yes tfJj)) Ifyes, describe: BP: II0/7 Lr- 02 Sat: R: I"/ 0) T:CJ"i•D P: G.5 DOB: Weight: Speech slurred: yes I© Alert & Oriented x 3:/ye§'/ no Ifno, describe: Skin : Normal l�V flushed /jaundiced / diaphoretic Skin t�ratw'e (Cold, bot, � normal): Heart (RRR, if DO describe): Oxygen use: yes ,fn(i.;If yes, amount: Lung sounds (biJateraJly): /' .J,?C,,__,,,,Abdomen: Normal:(yjs I no IfDo, describe: Last BM: /1 /1�11::fBowel sounds: /feJ I no Describe ifabnormal Last stool appearance (Color, consistency): lQ'oimal, Jfnot, describe: Neri- o L/J-.:!l' v ,A Incontinence ofurine: yes I/iOJ Foley: yes /JioJ Self-void:@Do Dressing type (describe): /\.l� Wound type: N_;,>A...{_ Size (in cm): Location ofwound: f'v/.� Signs oflnfectioD: yes,ff{ciJ Ifyes, describe: Drainage (amtlcolor): Hand/Ann strength (If applicable): Equal: �I no Ifno describe: Leg strength (If applicable): _ijqiiaJ: (@I no Ifno, describe: Edema: yes /rro Pedal pulses (Ifapplicable): Equal: f«j no Ifno, describe: IV location: - --.:Ff Type/Rate ofIV solution (if applicable): f\,t,.,,""--<. ofhours at current IV site (not> 72 hours): Condition ofIV site: v/ # Hunger Strike: yes� If yes, complete next 2 rows. Room checked for food by security? @I no Is I/DIR drinking H20? �/ no If no, when was the last H20 consumed?: Amt: -=/-& "'/., Last caloric intake: Date: II l- Time: /']-v-v Type: ,D,�v v /tr/, Comments: A: P+E: Lk'tL� -Iv (,,_,,,__;-.,) 7 "'-<- -Jut (v.....nte:fe.d r:,.._-rh ,,i." ·-,•,.A Clo NCH-Uc:, ,v-1 •.., ,f "t-,�._...,_ {/ NURSE'S SIGNATURE/STAMP AND DATE r (bt f/5 b)(6);(b)(7)(C) It j,,g /! t i2 e. c.. HS-142.6 'II J, Sill, J/13, 6114, 2/IS 2020-ICLl-00006 207 Facility Name P-.., 'Vf\"-1 RNlmt. V LL ON I RN 1ml C..,. \ (V'\� ()\\.-..IE. 0. I,.,,.,� RNlmt. j7 \7 _,, C CI t, "': A� J\ ('._ C. I b,l\:.\,oA.-t' RN Intl 69 2.:; «17 D.Jj P'L' u? f () {70 0. J I"") START DATE /�/$J7 fo (_ ALLERGY DIAGNOSIS ff'> A ' START DATE STOP DATE G?t-t--5 {70 -,-- l"O 11) z_q ),7 I DOCUMENTATION cooes'= DC - D1scontmued Order DO - Dose O mitted H Medical Hold (�t, IL.} �\ l)'-: Qq Q� Z-' V;,,, It, ? ,_b t I ' - - - -� f-- ·- f-- � - v-: w0 0� u I<° /""J7-:z...JC/1 \ - \, - - � ,,. - ?- I ..... 'J - I ---� - - - -- -- -- ,__ i--- - ,,,,,,,...... NURSE'S SIGNATURE { ... A - Refused C Cour t LO - Lock Down ,z '1 . I -7,, \101 � 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 I � �, STOP DATE l�/1,t//'1 il..rl/YIy f\'� 8 VI I '-11 7 :.J""' /5 t:,)-7), / Pf2.-/ 6 5 ' \ I{ N N�tt SA tv\ 1 m·, C' '7 � z_/ 1 7 STOP DATE �' IO )1 - PATIENT NAME ? , z. l 2../ ,r / STOP DATE\ Z/ 4 ',d.J t- 5,- �f\ ,1y 1l'D ri-/1 A 7 1-h cl.r 0){1�; .,,c_ so? AN Intl. 3,� uA.ly STOP DATE 7 2I , 7 h..'1 J1J STOP DATE JP)3)/'7 o., '> tD BIO START DATE II � 3 /1 l I � I' t( \ II/ i7 _It \I / START DATE I) C RNlmt ff) \.J p \-6 START DATE l I / 1 ?> J , C 1�"�..\� "� RN lnit (!) ?o START DATE I I / 1 "6) 1 l ?V1e N t; q ""-' ',1 2I v P -\-o �')( D�,,y STOP DATE l 'J./ START DATE \ 1 j I 'f<- I 11- 1500 ,.,,7 12) Z/ I':/ 2 e.. - r "7..J -<1 k!.1om1 ,::,C> up \-o -5.>< D,H7 ,-iJ i'tf - I Il:51.,\ V STOP DATE \ 2. / z/17 '6l 1 "t Y C.. \ 0 e,1=..tJ zApiZ. 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't1. 3 4- � (I/ I 5 C4 ,STOP I c}ml'.. 7 y' C Y ? uptc, �;-\')11-dy ec )( STARTDATE I\ J I Y,.II 1-, �A", I 212 ) 11- STARTDATE \ I J 1 �) , -:i_STOPDATE I I 0 L.,LO "--ll\�\t-/1:: RN 1ml 1.. (Y) 1 � m LI 2 NOV 2.0\ l ___ _ 1--t- :== ::-+-->---+_, . 1 =I __ 3-'r(l_ - ,I1� \��� trfr' � 17 'r - t��----+---+-�-+--�-----+--t---+-�r--+-��l ��-����i 1�l ' -----i � b)(6);(b)(7)(C) I r.,b)(6);(b)(7)( ';, ,- -r, f RNlmt STARTDATE\\}J'><-/1J-STOPDAT Et"2/2./11 •v ...!:!!�!!-2=----����� LlS,l,�L���:..1.�� .,J,J..L_-1-_--l1-�-l--4--..i..-1--1--1-4--4--4--4--l--.J-1-�,k ;t:, :;;; � ; � ,� � < ;e-; :--1---, ;z:rr;tic6:ii'. );lh(b¥)(7ni)(�C\) __._....,_ b)(6) (b (7) C) r � + 13,L-J 'l:,C'O� 1,4p �)l 1>"',1'1 --,-� L...I i..,.1--.- __..1 ---1� f------➔ �_--+_--+ -+--+--+--+--- +---+-+-- _j_ L.l. -L 1__J )I I 5 b)(6);{b)(7)(C) b )(6) l(b){6) Jb)(6);(b)(7)(C - � n.+ -�b,)(7 I � -l RN h· 1t \°'> STARTDATE I l / / � } 1 � STOPDATE J 7/ 1.J 1 ':J ---ff---+- -----1,--1--,-- -- --+----+---+----1 . 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PATIENT NAME DOCUM DC Dis STOPDATE I STARTDATE )"t,,f )1 "J , STOPDATE I "t- STOPDAE / A22732918 I SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: DO -Dose Omitted H • Medical Hold ' b\(7)( --- �i-- -�---+----! t------tt--+--t----il-t--t--t-+---t---t--t---i--+---+---+---+ -- +--+--- --t---t----t---t--+ -t --<+--it --t--t--t--+---t-----+--t---t---+---t--+-+-----lf--t-+---+--+--+ - -� -f-- -+--+-- +- - -- i-- ,_o '1_ s- -+---+--+---t----t-----1----lr---+--- --+---+---t--+---+---+- + + t---t� (---,+--- --+--+-+---+--t---+--+-+-+---lf--t-+->----= -- /'5JJ'/ /;/ i--4 I - 0 9---tl--t------t--t--t------t--t------t--t------t------t------t------t--t--t--t--t t--t--t--t--t--t--t-+----+---+--'-+-+--I --+--+---+--+--�-+---t--+-+---t--+---� --+---+-·+---+---+--+---+--I----I --t- ...L..£---tt--;-1--t--t--+---+- :�I I I ,,...._, __ (b)(6);(b)(7)(C) .. __ -I IRAN Nation: D IN 11/17/2017 16:00 ----'----------'--�- - G� I Mr,, \_ C • Court LO - LockDown -p -----11--,1----1---+--�+--'-----t-+----t---t--t--t--t---+--➔--+-+--t--il-t-t--t----t--+---+ ---ir--i V-/--=---tt--t--+-+-t---if-t--t-+--t---+--+--+--t--+--t--+-+-t---ii--t--t-+--+--+--+----+--1- _,_ "Z-l ,'1-- -z,,/Jy I - £ u C:-:.V= STARTDATE l 1 / 1 ',,, /1-:; STOPDATE \ '2., { STARTDATE I J RN lnit QO I ½- l'JL<..; , d' ....t.A�cd STARTDATE -f-- +:_ . - S - Self Administered NS - No Show 0 - Other -- I I I IL-------;-rl b)(6);(b)(7)(C)-. - I 2020-ICLl-00006 �SJ.R��ACY SUGGESTIONS RECOMMENDATIONS 00 NOT SIIPFArr:m: P..vc:,,..,�., ,....,,....,",. ........ - SIGNS 2 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TEMP. PULSE RESPIRATION BLOOD PRESSURE WEIGHT MEDICATIONS NOT ADMINISTERED PRN AND MEDICATIONS ADMINISTERED DATE DRUG/ STRENGTH TIME lt/1 b I I 9- D l)t:r) Al•vA.v REASON +tV\-t-c l5 11119 wj,7 \1/l7/f )- I b S" ��td{ frl\,-,. EFFECTIVE NURSE INT. DATE TIME DRUG/ STRENGTH REASON EFFECTIVE b)(6);(b)(7 (C) KEEP-ON-PERSON MEDICATIONS: INMATE SIGNATURE SIGNIFIES RECEIPT OF MEDICATION, ADMINISTRATION DIRECTIONS & EDUCATION MEDICATION: MEDICATION: # OF PILLS & DATE ADMINISTERED: # START/STOP DATES: START/STOP DATES: NURSE SIGNATURE: NURSE SIGNATURE: INMATE SIGNATURE: INMATE SIGNATURE: OF PILLS & DATE ADMINISTERED: MEDICATION. MED ICATION: # OF PILLS & DATE ADMINISTERED: # OF PILLS & DATE ADMINISTERED: START/STOP DATES: START/STOP DATES: NURSE SIGNATURE: NURSE SIGNATURE : INMATE SIGNATURE: INMATE SIGNATURE: l 2020-ICLl-00006 210 NURSE INT 3 C Facility Name t.,1{'t)(7 ?, A zoe/oJl?::. C. RN lrnt. ;i:- START DATE: I) a(:;, ..:1-, ,v10� ,'1.1M �'1>) �N lrnt fJ'b RN lnit I c..o.¢_ �..;.r-c_ rD START DATE ,, cov->--5, (?o )VJ J,? STOP DATE �Jt� /1al-? ,.;.� J'ZA' ), C-- RN lrnt. � START DATE I/ }z.A ), 7 ;�y ,�Jr ),--7 /I,"':> I )( }O STOP DATE RN lnit START DATE STOP DATE RNlrnt. START DATE STOP DATE ALLERG Y )IA G NOSIS PATIENT NAME I z,,J1,A7 -j �y I --Z, tS?J7 -- - -,__- -- - - -f-- ,-- - -f-- - -- - ·-- -- - ·- f-- -- ,_ -�- I I I NURSE'S SIGNATURE INITIAL I I -- ·- - f-- >- --- ·- NURSE'S SIGNATURE Jt"'l{_,2__/fr _LS..,-"": ""'·, DOCUMENTATION cooe's = DC - Discontinued Order DO - Dose Omitted H - Medical Hold ,.,,,i::-4_ -==1�---,- K�M-f4/ R - Refused C - Court LO - Lock Down ID - ·-.___ STOP DATE START DATE ' b)(6);(bl STOP DATE START DATE RN ln1t ,_, - 4v - RN lrnt -I 7� STOP DATE START DATE -- - - RN lnit ) r1 (7)(C) �\.-- '{'I'\� 7 STOP DATE #K�c.. �""'�r� \e>�S� ft 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 I I ' I L-� - Zl- Jt.}p� )r7 STOP DATE x HOUR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 p� Q-\-\5 f� � �� u;.-+ START DATE I/ o�r C /00) Month/Year w1NG . Zi z75 1,� S - Self Administered NS No Show 2020-IC 0 - Other ---- 1-00006 iiiRMACY SUGGESTIONSiRECOMMENDATIONS DO NOT SUPERCEDE PHYC:lr.tAN nnr,i:r,c, ·-INITIAL UCH Rightfax Serverl 12/4/2017 6:04:52 PM PAGE l/015 Fax Server University of Colorado Hospital Health lnforrnat1on Mgrnt 12605 E 16th Avenue Aurora, CO 80045 0 720-848-1031 F 720-848-5551 Communication Date: 12/4/17 To: Geo Group,lnc Attn: GEO GROUP.INC Fax: 303-341-2652 Phone: 303-361-6612 From: fb)(6);(b)(7)(C) UGH Health Information Management ion contained in or attached to this fax message is privileged and confidential information. inte, 1 amed above. If the reader of this message is not the in n, or the employee or the use of the in , ded recipient notified that any disclosure. dissemination, agent responsible to deliver I · · d. If you have received this communication in error. please 1c distribution or copying of this comm us immediately by telephone and return documents to us by mail. PLEASE CALL THE SENDER BACK IF YOU RECEIVED THIS FAX IN ERROR. 2020-ICLl-00006 212 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE Patient Information R11r.P. Qrh"r Karnyar. Sarnimi PI1one ACICl[e&s �1lk1l0Wtl 222.222-2222 (Home) ,._URORA CO 80010 E1hni�Jry Non·Hi�p11nic Fax Server MRN: 5960219, DOB: 1/3/1953, Sex: M Adm: 12/2/2017. D/C: 12/2/2017 Demo ra hies Palienl Name samimi Karnyar 2/015 - ______,________ ,______ Prnf;,rr;,<1 L11ng1rngia Engli�h Tx Team Provider ··· tb)(6);(b)(7)(C) Encounter Diagnosis Comrnents ···-·····- .. ..... .............. , .. ••·••·•• ••·••············· .. ··· ••·••····••·• .... , .. ............... . Not on File Social Histo Num.: Results do not include all patient labs during this encounter. These are all labs from the last 24 hours of the patient admissioni or encounter. Please contact the lab for additional results. Resulted Labs for the last 24 hours of patients admission/encounter. •• No results found for the last 24 hours.•· Current Immunizations No immuni711tinn5 nn f1!P.. Procedures and Imaging No orf1 Filed . 214?◊17 "'QI} PM ·· · · ······se,�ice·: ·eME.RGEiiicv·ME.6ic·ii1iE······· ·· ·· ·· ·· ··············:.;;;;;,:;,,;· +·ype Pn si�;�;,···· ····· ·· ·· ·············· ··· y Dale 01 Servic::e. 12/2i2017 11 45 AM Slal11S. Ad(le,,a,Jon ProcA!rture Orrters: I. INTUBATION (367071082) <>rrtHP.::·::::: ::.:�::::-:-::.:·:::::. ,•,· ·• Patient seen in conjunction with�fb l_ <6_ >_;(b)_ <_ 7><_ c_ > _________· _ ··-_ ···_ _ · �·Isee their ��.t� for additional details. We were n ot able to obta in full details on p atients HPI, PMH/PSH, family history, meds/allergies and ROS secondary to patient s condition on arrival. [Unresponsive, cardiac arrest] 64 y.o. male Chief complaint: Cardiac Arrest There were no vitals taken for this visit. Head:NC,AT Eyes: no erythema, no discharge. Pl1pils are 4mm, fixed, and dilated. ENT: nl ext ears, nl ext nose Neck: supple, vomitous in his airway Back: no obvious deformity Pulm Equal breath sounds Card: no carotid pulse, no cardiac activity Abd: soft, NO Ext: NT Neuro: no facial asymmetry lnteg: no diaphoresis, no cyanosis GU: Rectal Exam: no obvious melena IMPRESSION: My differential diagnoses includes but is not limited to: As above, PLAN: ED COURSE: 11 :43 AM: Pt arrived to ED by EMS with CPR in progress. 11 :46 AM: Stopped manual CPR, started automatic compressions. 11 :47 AM: I-Gel in place, not breathing spontaneously. Vomitous in his airway, pupils are 4mm, fixed, and dilated. Carotid pulse now, equal breath sounds. Conjunctiva are pale. Positive color change 11 :49 AM: No carotid pulse. Stopped compressions. 11:50 AM: Continued compressions. 11 :51 AM: Pulse check. no carotid or femoral pulses 11 :53 AM: Pulse check: no carotid, no cardiac activity 11 :55 AM: Pulse check. ContinL1ed asystole/PEA with no palpable pulses. 11 :58 AM: Pulse check: No pulse, will resume CPR. 12:00 PM: Pulse check: back in asystole, no carotid or femoral pulse. No cardiac movement on US Will Printed by 5172 at 12/4/17 2:41 PM Page 3 2020-ICLl-00006 214 UCH RightFax Server! 12/4/2017 6:04:52 PM AMC EMERGENCY �r. �-°--·�-r���.�.�•:.�.?�-��.. °.. PAGE 4/015 Karnya,, Sarnimi MRN: 5960219, DOB 1/3/1953, Sex M Adm: 12/2/2017. D/C: 12/2/2017 r,,,�.". 3.w_ �,. � _ri·-�·..� 3.'. 1.�'..�!.��.1.!..�.�.:�.� .�r.1. (�� .i�.��.�). ······ .. . .. . .. . . .. . .. ..... ........ . 1 1 o Fax Server tlt __ ,._ ........................... ·•·•····........... ............. ········· ..... resume CPR. 12:02 PM: Called time of death after 35 minutes of CPR. 12 10 PM Called coroner to discuss pl s case. 12:27 PM: Labs: Trop 0.08, Chem with na 126, bicarb 15. glc 416, er 1.8 12:38 PM: I reviewed the paperwork from Aurora Detention Center and he went to the medical center there for "withdrawal, suicide watch, dehydration, NN". 1:00 PM: Adams County coroner called back and will transfer jurisdiction to Arapahoe and requested that the body be put on coroner s hold. 1: 13 PM: Adams County called back and verifed that he was at a federal facility. Detention Center is speaking to staff now for a disposition plan. Staff notes we can transfer body to morgue on a coroner s hold. They ask that we place brown bags on the hands. Addend: Trap 0.08, Chem with na 126, bicarb 15, glc 416, er 1.8 Cili◊t C<>mpl<1im: P1..)ift�fit t->n:stn,��; �Y!H: • Cardiac Arrest HPI Samimi Kamyar is a 64 y.o. male who was BIB EMS with unknown PMHx who presents to the ED today initially for vomiting in his jail cell. When EMS arrived. they noticed blood in his vomit. He was in a prone position on EMS arrival and they saw that he was not breathing well on his own, probably breathing about 2 breaths per minutes, with very little movement Pt was warm to the touch and EMS started compressions. EMS reported that at the call for them was received at 11: 17 AM this morning, pt was apparently vomiting and moving. EMS arrived on scene and initiated ACLS @ 11 :25a as pt had stopped breathing. EMS performed compressions for approximately 19 minutes PTA. Pt has been down for roughly 22 minutes total. EMS gave pt three rounds of epi PTA. Pt went into A Fib at one point which was when EMS shocked him x1. No past medical history on file. No past surgical history on file. No family history on file. S<>i.:i,1! i·Usiwy �t.ff)�hH•)·r:.e U:�t.'., T!.'lp:( r":i • Smoking status: • Smokeless tobacco: • Alcohol use Not on file Not on file Not on file Review of Systems Unable to obtain ROS 2/2 cardiac arrest. There were no vitals taken for this visit. Physical Exam Page 4 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 215 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 5/015 Fax Server Kamyar, Samim, MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017, 0/C: 12/2/2017 Prior to procedure, hands were washed and sanitary- conditions observed. Intubation Date/Time: 12/2/2017 11 :47 AM Performed byj(b)(6);(b)(7)(C) Authorized b�------------' Consent: The procedure was performed in an emergent situation. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Ti me o ut: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: respiratory failure Intubation method: direct Patient status: unconscious Preoxygenation: BVM Pretreatment medications: none Laryngoscope size: Mac 4 Tube size: 7.5 mm Tube type: cuffed Number of attempts: 1 Cricoid pressure: no Cords visualized: yes Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector Breath sounds: equal Cuff inflated: yes ETT to lip: 24 crn Tube secured with ETT holder Patient tolerance of procedure: Intubation performed during cardiac arrest. Time of death ultimately called. CPR Date/Time: 12/4/2017 12:03 PM Performed by b)(6);(b)(7)(C) � Authorized b-,i__________� Consent: The procedure was performed in an emergent situation Verbal consent not obtained. Written consent not obtained. Required items: required bl ood products, implants, devices, and special equipment available Patient identity confirmed: anonymous protocol, patient vented/unresponsive Local anesthesia used: no Anesthesia: Local anesthesia used: no Sedation: Patient sedated: no Comments: CPR x 20min DEATH note: Date and time of pronouncement 12 2 17, 12:02pm Pronouncing physician nameJ(b)(6);( b)(7)(C) I Attending physician signing the death certificate: deferred to coroner Date and time of coroner notification: 12: 1 Op Page 5 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 216 UCH RightFax Serverl 12/4/2017 6:04:52 PM PAGE AMC EMERGENCY 6/015 Fax Server Karnyar. Sarnirni MRN: 5960219, DOB: 1/3/1953, Sex: M Adm: 12/2/2017. 0/C: 12/2/2017 �.'?..�.��.V.i�.e.r..�.�,.��..�K--��.".�.�.�.".�!..��.r�. �:.�.?...�!..�.���!.��-1.!.�.�. :�.�.��.1�.�� 1.i�.���.>. ............................................ ............. ........ ........................................................ Coroner investigator s name: see paperwork w/decedent affairs Coroner instructions: may move body to the morgue in a body bag, put brown bags on the hands, body is on a coroner s hold. l a_t_te_s_·t_ t_h"'"'t tt1is documentation !·1as been prepared under the By signing my name below, 1,j._< b)(6) ;(b)(?)(C ) � , ;;;, =; ;;;,; =; =; '= =; �=== _ direction and in tl,e presence ofKb)(6);(b)(7)(C) I pcribe. 12/02/17. 12:32 PM i'M EIP.r.tronic.Rlly sign<'<1 h y .ll 12/2,'2017 12.46 PM E1eclronii:.111y $i,1ne<1 by .ll 12'212017 1.00 PM EleClfOlliC:llly $i(1ne.�.. ........... .. b)(6);(b)(7)(C) 12/4/2017 12:02 PM 7/015 Fax Server Karnyar, Sarnim1 MRN: 5960219, DOB: 1/3/1953, Sex: M Adm: 12/2/2017, DIC: 12/2/2017 Pr<>vi·..··.. ··· ..·..··.. . Sign 12/2/2017 11:46 Date 01 servir.e. 12'21'2017 11 4G .L . . . . . . . . . . . ..... , ...... ,,,,, .• , AM .. ........... .. ·R;;ciisi,;,;;ii Nii,�;;.. . ...... .. . . . . .... .......... ,;,:;;iiio,1'vnri Slalu�. Si�Jrl�=60 L AMC Lab ml/min/1.73 "square meters" Comment: Component Sodium POC 00,.,.. ,..,, eGFR estimated by IOMS-traceable MORD Study equation for ages 18-70 years Not validated for use during Printed by 5172 at ·12/4/17 2:41 PM Page 9 2020-ICLl-00006 220 UCH RightFax Server! 12/4/2017 6:04:52 PM 10/015 PAGE AMC EMERGENCY Fax Server Karnyar. Sarnimi MRN: 5960219, DOB: 1/3/1953. Sex: M Adm: 12/2/2017. DIC: 12/2/2017 pregnancy, acute illness, or in peo ple with unique diets or abno rmal muscle mass. POCT eGFR African American 49 >=60 mUmin/1 . 73 "square meters" Comment: AMC Lab L eGFR estimated by !OMS-traceable MORD Study equation fo r ages 18-70 years. Not validated fo r use during pregnancy, acute illness, or in peo ple with unique diets or abnormal muscle mass. Anion Ga p POC '••·• ,.., • ' ' •· ••• ••• •••••• ••• • ' , . , '"•• '" '" • ' -�• •• ·''"'"''' •• •••• ••••••••• ••••" •• T esting Performed By Lab -Abbreviati o n 233 -AMC Lab Name ANSCHUTZ MEDICAL CAMPUS LAB, AURORA, CO 22 ;.•• •" ••· ••· ••• ••• V' ••• • ••• ••• •• Directo r b)(6);(b)( 7)(C) •• • • ''" ,, ••• ••·•••••• ••• •••••• • . POCT I STAT Chem 8 + [367071084] Electronic a lly signed by: Edi, Poet on 12/02/17 1211 Ordering user: Kb)(6);(b)(7)( 12/02/17 1211 Ordering mode: Standard ,,.,, •• AMC Lab ••· • · • •••v• •• · •• ••• • ••• •• .. ,.. ,•••• ;.•• ••• • • • , Valid Date Range 05/03/16 1239-Present � . . .. ':. .. · POCT I STAT Chem 8 -t [POC2138] (Order 367071084) · ��-�----_,Sta tus: Completed Authorized by:fbl(6);(b)(7)(C) I POCT I STAT Chem 8 + Status: Final result (Collected: 12/2/2017 12:06) Results Abnormal POCT I STA T Chem 8 + [367071084) (Abnormal) Filed by: Lab, Backgro und User 12/02/17 1211 Result details Specimen Informati o n Type ••• • · ,,,,, .. ••• •• Address 12401 East '17th Avenue Campus Box A022 AURORA CO 80045 Order Com H rn - 20 rnmol/L •·. ••· ••• •· '•" •• Source Blood Resulted: ·t 2/02/17 1211, Result status: Final result Resulting lab: ANSCHUTZ MEDIC AL CAMPUS LAB, A URORA, CO Collected On 12/02/"I 7 1206 o nents Reference Flag Lab Range Value Component AMC Lab L 133-145 126 Sodium POC . ... ,..... ....,,.......,. ...,.... _.,. . . ,.. ,. ........................... .... .. ....,.,.. .. ........ mmol/L....... .. , ......, ..,.... .......,..,. ... .., ...........,.. ... .. . .. . ,.. . ,........ ,. ......,... ,.......................... ...... ...... .... .............. .....w.......,.•.•• . .1.. mmol/L. . .. - ......... . . . .. ... , .... AMC.Lab ......... ,. . . . .... .. ., Potassium. POC.. ... . _....... . .. ...... ,. .._. . .......... 3 .. 5 .,.... ..... .........3.5. -5 98 - 108 rnrnol/L L 93 Chloride POC AMC Lab . .. TC02 Venous,. POC.. . ,.. ... ,.,...... ... ............................. .. .. ...... .. .. 1-.5 ..... ........ .....,. ... ,.. .....2 1,.-..31.., mmol/L..... .. ,. L...... w., .. ............,.....,.,...,.•. AMCJab . ................ ,. ..... ..... ...... . 41.9...... . . . ... ,. ... .7-0.. :J.��.JlJQ/9.L.... Ji.. ..... . . . ..... .. . ... ...�ry,�_J{l. t?. . . , .... ,.. ... . . . .. .. .. . .. G.L\!9.9§�.P-99-. __.. ..... ... .. .. .. .......... ... ...... BUN POC 7-25 rng/dL H 83 AMC Lab ..........w.• w Page 10 Printed by 5172 at 12/4/17 2 41 PM 2020-ICLl-00006 221 UCH RightFax Server! 12/4/2017 6:04:52 PM ucbeaitb-- AMC EMERGENCY -- _cre_aJipine POC . . . POCT eGFR Non African American 1.8 40 Comment: PAGE 11/015 Fax Server Karnyar, Sarnimi MRN: 5960219, DOB. 1/3/1953, Sex: M Adm: 12/2/2017, DIC: 12/2/2017 _0. 7 - 1.3 rn!=JI�!- >=60 ml/min/1. 73 "square meters" H L .... AMC Laq . AMC Lab eGFR estimated by !OMS-traceable MORD Study equation for ages 18-70 years. Not validated for use during pregnancy, acute illness, or in people w,th unique diets or abnormal muscle mass. POCT eGFR African American 49 Comment: >=60 ml/min/1. 73 "square meters" L AMC Lab eGFR estimated by !OMS-traceable MORD Study equation for ages 18-70 years. Not validated for use during pregnancy, acute illness. or in people with unique diets or abnormal muscle mass. Anion Gap POC Testing Performed By Lab - Abbreviation 233 -AMC Lab 22 Name ANSCHUTZ MEDICAL CAMPUS LAB, AURORA, CO Director (b)(6);(b)(7)(C ) AMC Lab Address 12401 East 17th Avenue Campus Box A022 AURORA CO 80045 INTUBATION Valid Date Range 05/03/16 1239- Present Status: Edited Result - FINAL (Resulted: 12/2/2017 11 :45) Results Resulted: 12/02/17 1145, Result status: Edited INTUBATION 367071082 Result - FINAL Ordering provider: (b)(6);(b)(7)(C) Filed by: (b)(6);(b)(7)(C) 12/04/17 1206 12/02/17 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL - AURORA, CO Narrative: 12/4/2017 12:06 PM Montagna, Lori A. MD Intubation Date/Time: 12/2/201711:47 AM Performed by: (b)(6);(b)(7)(C) j Authorized by ..__-------,--- --,-,� Consent: The procedure was performed in an emergent situation. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: respirator'y failure Intubation method. direct Patient status: unconscious Preoxygenation: BVM Page 11 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 222 UCH RightFax Server! 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 12/015 Fax Server Kamyar. Sarnimi MRN:5960219, DOB. 1/3/1953, Sex: M Adm: 12/2/2017, D/C: 12/2/2017 Pretreatment medications: none Laryngoscope size: Mac 4 Tube size: 7 .5 mm Tube type:cuffed Number of attempts: 1 Cricoid pressure: no Cords visualized: yes Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector Breath sounds: equal Cuff inflated: yes ETT to lip: 24 cm Tube secured with: ETT holder Patient tolerance of procedure: Intubation performed during cardiac arrest. Time of death ultimately called. Testing Performed By Lab - Abbreviation 69 - Unknown Name UNIVERSITY OF COLORADO HOSPITAL­ AURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 Order Valid Date Range 04/03/14 1716- Present INTUBATION [PR089) (Order 367071082) INTUBATION [367071082] Electronically si ned b : Truong, Cecilia on 12/02/17 1203 StatiJs: Completed Ordering provider: ....b_)( 2/02/1 7 1203 Ordering user: (b)(6);(b)(7)(C) �6);_ (b_ )(7)(C _ _ l____ � � Ordering mode: Standard Authorized by: !/bl< 6l/bl/7l/Cl Order comments: This order was created via procedure documentation �I INTUBATION Status: Edited Result - FINAL (Resulted: 12/2/2017 11 :45) Results Resulted: 12/02/17 1145, Result status: Edited INTUBATION 367071082 Result - FINAL 12/02/17 Filed by: (b)(6);( b)(7)(C) 12/04/17 1206 Ordering provider: b)(6l;(bl(7l(C) 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL - AURORA, CO Narrative: Montagna. Lori A. MO 12/4/2017 12:06 PM Intubation Date/Time 12/2/2017 11:47 AM Performed by b)(6);(b)(7)(C) � Authorized by(______________. Consent: The procedure was performed in an emergent situation. Required items:required blood products, implants. devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient. procedure, equipment, support staff and site/side marked as required. Printed by 5172 at 12/4/17 2.41 PM Page 12 2020-ICLl-00006 223 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 13/015 Fax Server Karnyar. Sarnim, MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017. DIC: 12/2/2017 Indications: respiratory failure Intubation method: direct Patient status: unconscious Preoxygenation: BVM Pretreatment medications: none Laryngoscope size. Mac 4 Tube size 7.5 mm Tube type: cuffed Number of attempts: 1 Cricoid pressure no Cords visualized: yes Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector Breath sounds: equal Cuff inflated yes ETT to lip: 24 cm Tube secured will): ETT 11older Patient tolerance of procedure: Intubation performed during cardiac arrest. Tune of death ultimately called. Test,ng Performed By Lab - Abbreviat,on 69 - Unknown Narne UNIVERSITY OF COLORADO HOSPITALAURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 Valid Date Range 04/03/14 1716 - Present Status: Final result (Resulted: 12/2/2017 11 :45) ED CPR PROCEDURE Results Resulted: 12/02/17 1145, Result status: Final ED CPR PROCEDURE 367071096 result Ordering provider: b)(6);(b)(7)(C) 12/04/1 7 Filed by b)(6);(b){7)(C) 2/04/1 7 1206 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL -AURORA, CO Narrative: Fb)(6);(b)(7)(C) ! 12/4/2017 12:06 PM CPR Date/Time: 12/4/2017 12:03 PM Performed byfb)(6);(b)(7)(C) Authorized by L.. _____ ______, Consent: The proceclure was perfonnecl in an emergent situation. Verbal consent not obtained. Written consent not obtained. Required items: required blood products. implants, devices, and special equipment available Patient identity confirmed: anonymous protocol. patient vented/unresponsive Local anesthesia used no Anesthesia: Local anesthesia used no Printed by 5172 at ·12/4/17 2.41 PM Page 13 2020-ICLl-00006 224 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 14/015 Fax Server Karnyar. Samimi MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017. DIC: 12/2/2017 Sedation: Patient seclated: no Comments: CPR x 20min Testing Performed By Lab - Abbreviation 69 - Unknown Name UNIVERSITY OF COLORADO HOSPITAL­ AURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 Order Valid Date Range 04/03/14 1716 - Present ED CPR PROCEDURE [EO2031] (Order 367071096) ED CPR PROCEDURE 367071096 MD on 12/04/17 1203 Status: Completed Electronically signed by (b)(6);(b)(?) (C) Ordering user: (b)(6);(b)(7)(C) Ordering provider: ._l(b)_ (6);_ (b)(7_ )_(C_)____I 2/04/17 1203 ..,... ....... Ordering mode: Standard Authorized by: ""'-=----=--:-::;-:--=- -=-:--=-:-::-=-=Order cornmen�ts:-his order-was cre ated via procedure documentation ED CPR PROCEDURE Status: Final result Results (Resulted: 12/2/2017 11 :45) Resulted: '12/02/17 1145, Result status: Final ED CPR PROCEDURE 367071096 result Ordering provider. (b)(6);(b)(7)(C) Filed by (b )(6);(b)(7)(C) 12/04/17 1206 12/04/1 7 1203 R esult details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL - AURORA, CO Narrative: 12/4/201 7 12:06 PM Montagna, Lori A, MD CPR Date/Time: 12/4/2017 12:03 P M Performed by (b)(6);(b)(7)(C) Authorized by,_j , _________ Consent: The procedure was performed in an emergent situation, Verbal consent not obtained, Written consent not obtained. Required items: required blood products. implants, devices, and special equipment available Patient identity confirmed: anonymous protocol, patient vented/unresponsive Local anesthesia used: no AnestMsia: Local anesthesia used: no Seclation: Patient sedated: no Comments: CPR x 20min Page 14 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 225 UCH RightFax Server! 12/4/2017 6:04:52 PM uctJeal:tb---Testing Performed By Lab - Abbreviation 69 - Unknown AMC EMERGENCY Name UNIVERSITY OF COLORADO HOSPITAL· AURORA, CO Director Unknown ------------------__ ,___ _ , _ U U_O -• --•,_, • 1.---�-tl1111111 fltt, .. 11:•H♦ttl I PAGE 15/015 Fax Server Karnyar, Sarnim1 MRN: 5960219, DOB. 1/3/1953, Sex: M Adm: 12/212017. DIC: 12/2/2017 Address 1635 NORTH AURORA CT AURORA CO 80045 Valid Date Range 04/03/14 1716- Present ------------♦-PH _______ END OF REPORT ---- Page ·15 Printed by 5172 at 12/4/17 2.41 PM 2020-ICLl-00006 226 PROGRESS NOTES Inmate/Detainee/Resident (I/DIR) Name: 1/D/R #: Facility Name: Aurora Detention Center Date/Time I l 2.,7 / HS-166 Rev I/OS, 1/13, I/IS 2020-ICLl-00006 227 MEDICAL OBSERVATION NURSING PROGRESS RECORD FACILITY: �\)-,j?� ( Datdfime lnmatt/Deuinee/Resident {I/DIR) Name: _ALLERGIES:_(�V....i,. � .....Dt\ .:..,,,,u._,.______ DOB: :>00 - Chest pain: yes / no Jf yes, describe: Abdominal pain: yes / no Jf yes, describe: Other pain: yes / no Jf es, descnl>e (Pain 0) T: Alert e I flushed /jaundiced / diaphoretic Sk:int Heart Oxygen use: y Lung so Abdomen: yes, amount: Last BM: Location o Drainage (amt/col Hand/Arm stJength (I Leg strength (If appli Commenb: A: P+E: t NURSE'S SIGNATURE/STAMP AND DAT "111, 5/11, 1/13, 6/14, 2/15 b)(6);(b}(7)(C} ----J--------L--- HS-142.6 2020-ICLl-00006 228 PROGRESS NOTES Inmate/Detainee/Resident (I/DIR) Name: )CtM}M.' I k {,.1"1., '-(4,,/ 1/D/R #: 'l"L 7 }'L'11 � DOB: t/>/S7 Facility Name: Aurora Detention Center Date/Time HS-166 Rev 1/05, 1/13, I/IS 2020-ICLl-00006 229 PROGRESS NOTES Inmate/Detainee/Resident (1/D/R) Name: sA (\I) I {Y\·1 IL.Am \J ft 1-z_ J/D/R #: DOB: 2.27'3.2°t1¥ I /3/ Facility Name: 53 Aurora Detention Center Date/Time \ I 20 Ff l Ifs 0 lj1 -, ,'6, I fl v. : .Q , R. I& -------------l b)(6);(b)(7)(C) c:Jn � rO � q '( o O \"'"1> IY'I � 1 '( , (b)(6);(b)(7)(C) Rev 1/05, 1/13, 1/15 HS-166 2020-ICLl-00006 230 ATTACHMENT J Ge® INITIAL SUICIDE RISK ASSESSMENT I/DIR#: Inmate/Detainee/Resident (I/DIR) Name: Referral Source: , DOB: Facility Name: __________________ S: 0: Findings: Assessment and resulting recommendations are based on the following: (check all that apply) D Cell/Property Search D Clinical Interview D I/DIR Interview D I/DIR Phone Call D Medical Record D I/DIR Writing D Other Health Record Reviewed: Yes D No D Type of Attempt: D Han1?in2 D Jumoiniz D Cutting D Ingestion D N/A D Other o IdeationNerbalization D Other Did the 1/D/R Communicate Self Injury: Yes D No □ Lethality Assessment associated with self-iniurv: Did I/DIR communicate a suicidal plan: Yes D No D If yes, please describe the plan: Did I/DIR communicate suicidal intent: Yes D No D If yes, please indicate what I/DIR reported: History: Developmental History (Hx): Educational Hx/Cognitive: Arrest Hx and Experience: Mental Health Hx: Self Hann Hx: Family History of Mental Illness/Suicide Attempts: Substance Abuse History: 2020-ICLl-00006 231 ( ATTACHMENT J INITIAL SUICIDE RISK ASSESSMENT ( CONTINUATION Inmate/Detainee/Resident (I/DIR) Name: I/DIR#: DOB: Facility Name: RJSK FACTORS ASSESSED: DYNAMIC FACTORS: D Chronic Medical Condition D Family hx. of suicide D High Profile Crime D Hx childhood abuse D Hx inpatient mental health tx D Hx Mental IJlness D Hx of self-injury / suicide thoughts D Hx of violent behavior D Sex offender status D Homicidal ideation D Requested Protective Custody D Victim of Sexual Assault D Lack of family connection D Recent incident: D Other D D D D D D D D D D D D D D D Agitation Current Intoxication Current physical pain Current Suicidal Ideation Current Suicidal Plans Fear of own safety Feeling hopeless/helpless Feeling like a burden Non-compliance with tx Problem solving deficits Recent significant loss Sleep Problems Social Isolation Change in appetite Impulsive PROTECTIVE FACTORS: D D D D D D D D D D Able to identify reasons for living Adequate Problem Solving Denial of Suicide Ideation Future Orientation Religious belief against suicide Social Support in the institution Supportive Family relationships View of death as negative Willingness to engage Actively seeking mental health treatment 2020-ICLl-00006 232 ( ATTACHMENT J INITIAL SUICIDE RISK ASSESSMENT CONTINUATION DOB: I/DIR#: Inmate/Detainee/Resident (I/DIR) Name: Facility Name: Current Mental Health Status (Please address all items): J. Appearance Eye Contact 2. Attitude 3. Behavior Appetile/Sleep 4. Psychomotor Activity 5. Attention/ Concentration 6. Speech 7. Affect 8. Mood 9. Thought Process 10. Thought Content □ □ well groomed □ poorly groomed good hygiene o poor hygiene o other (describe): Eye Contact good □ooor o other (describe): o calm and cooperative other (describe): D no unusual movements or psychomotor Appetite: WNL □ increased o decreased changes Sleep: D WNL o increased decreased o other (describel: agitation retardation o normal o normal o poor o distractible/inattentive Pressured Slowed normal rate/tone/volume w/o pressure a other (describe): o blunted o depressed o reactive & mood congruent normal range o labile o constricted tearful o other (describe): o flat anxious euthyrnic o depressed o irritable elevated other (describe): goal--directed and logical disorganized o other (describe); If active: plan YIN intent YIN means YIN Homicidal ideation: o none o passive a active □ □ □ □ □ □ □ □ □ □ □ □ □ o Phobias o no hallucinations or delusions during interview I J. Perception □ other (describe): I 2. Alert/Orientation Alert: fully a distracted a tired/sleepy o other (describe): situation Oriented: o time o place o person short term intact o other (describe): good fair □poor □ below average o average a above average 14. Insight/Judgement 15. Estimated IQ □ □ □ o delusions o obsessions/compulsions o other (describe): 13. Memory □ □ □ □ □ □ 2020-ICLl-00006 233 o long term intact ATTACHMENT J ( ( INITIAL SUICIDE RISK ASSESSMENT CONTINUATION Inmate/Detainee/Resident (1/D/R) Name: A: P: I/DIR#: DOB: Facility Name: Safety secondary to Suicidal Ideations: Overall Acute Suicide Risk for this inmate is: Low Moderate High Overall Chronic Suicide Risk for this inmate is: Low Moderate High D Suicide watch NOT necessary at this time Follow up on: PRN D Date ____ D Admit to Suicide Watch. Level --Begin Security checks with Observation Checklist. D I/DIR to be seen by a Mental Health Professional on daily basis when on site at a minimum of every 72 hours. D Health Services Administrator or Director of Nursing and Staff Duty Officer notified. D Nurses to chart on inmates activity and behavior every shift. D Food is to be served in a sack lunch style, no utensils and no cellophane. □ Refer to a Psychiatrist D Refer to Psychologist D Referral form completed □ Education Provided Related to Current Assessment: MENTAL HEALTH PROVIDER: __________________ Date: --------- (SIGNATURE & STAMP) Time:---------- 2020-ICLl-00006 234 . ' Attachment G SUICIDE WATCH LOG AND NOTES Date: I Unit: Inmate/Detainee/Resident (I/DIR) Name: Check appropriate level of observation: Level 1 D Constant Observation The GEOG roua. nc. I Shift: Inmate/Detainee/Resident (I/DIR) I Location: Number: Level2 □ Fifteen Minute Checks Restraint Type: ________________________ □ □ □ □ □ Items allowed (check appropriate box): Suicide Mattress Suicidal Blanket Book CJ Suicidal Pi1low Code Explanation l. Beating on door/wall 2. Yelling or screaming 3. Crying 4. Cursing 5. Laughing 6. Sincing 7. Mumbling incoherently 8. Standin2 still 9. Walking 10. Lying or sitting 11. Quiet 12. Sleeoing 13. Meals served/eaten 14. Fluids served/taken 15. Bath/Shower 16. Toilet 17. Smoking J 8. Restraints Loosened 19. Range of Motion 20. Other 21. Other Time Undergarments Other: Visual Time Checks Made on 1/D/R Initials Code Tne n Code Initials Code and signature required on the above time lines per level of observation. StaffSionatures Initials StaffSionatures Initials I have reviewed the above log and certify that for the shift noted above, the I/DIR was observed in accordance with the requirements of level of observation. Supervisor : Print Name Signature Date Time Suicide Watcl, Lo2/Notes Form # HS-207.5 Rev: 0212014, 05/2017 2020-ICLl-00006 235 ( A ttachment C Suicide Alert - PENDING The GEO Group, Inc. Inmate/Detainee/Resident (I/DIR) Name: Location: !Vlfd,cevt s� Inmate/Detainee/Resident (I/DIR) Number: =,-3 :l. I 'ii? kafV\�r- Cf D� I Race/Ethnicity: '�tl<-N rY1 (- l"Y1 � / I Sex: IV\ SPECIAL INSTRUCTIONS I b<..-<.,c:(k_. y>tUoc.,...) L. n� r 1 3· �&'\. r $'""-;'c..,'ck 1 O r-i I b Lc..v,_hl M,"""' I ,'-re- I� S LA-,- Cc' d..e.. �L 'J-- o s h.e..vt...s 6'+ � ; LR -t- pc. r e. I"" , I s rvi.�t L h�•tr-, f,-od s 1ei p..e r- Gfoo rt �:.l'O � c;-r ()a......,..-. J 'R tl-su.­ ·IA.., 1 � 1/D/R WILL BE PLACED ON SUICIDE ALERT-PENDING LEVEL 1 - PENDING I/DIR REQUIRES ONE-ON-ONE SUPERVISION Staff member within fifteen (15) feet ofl/D/R b)(6);(b)(7)(C) 1gnature ate Time Print Name and Signature Date: Time Health Services Print Name and Signature Date: Time This form will be placed in the medical record. After immediate verbal notification of_placement on Suicide Level 1 status a cop_y of this form will be distributed as follows: The Facility Warden, The Assistant Warden of Security, and The Chief of Security/Designee. 2020-ICLl-00006 236 Attachment D Suicide Alert - LEVEL 1 see Th• GEO Group, tnc. Inmate/Detainee/Resident (I/DIR) Name: Location: Inmate/Detainee/Resident (I/DIR) Number: Sex: I I Race/Ethnicitv: SPECIALINSTRUCTIONS: LEVEL l CONTINUAL OBSERVATION BY STAFF 1/D/R WILL BE PLACED ON SUICIDE ALERT I/D/R REQUIRES CONTINUAL LINE OF SIGHT SUPERVISION. Print Name and Signature Date Time Print Name and Signature Date: Time Health Services Print Name and Signature Date: Time This form will be placed in the medica) record. After immediate verbal notification of placement on Suicide Level 1 status a COP.Y of this form will be distributed as follows: The Facility Warden, The Assistant Warden of Security, and The Chief of Security/Designee. New 1/13 Rev: 05/2017 Suicide Alert - Level l Fonn # HS-207.2 2020-ICLl-00006 237 ( ··'_ j 680 ........... lne, MEDICAL OBSERVATION NURSING PROGRESS RECORD ( FACILITY: Date/Time I I l\ \1117 II,?--r) � � S) ALLERGIES: __,__ �_Kf)_A�------ - I !f-1� 32� 'l t (I/DIR) Name: K 6\ YV\, Y\I'\' 1 Il VV\. \.In r te/Deta,inee/Resi lI If1; .,�� 1 l � r +-em�l+' , , ,,...--..,. Chest pain: yes };,no "JJy�s. describe: Abdominal pajo.; yes (noJfyes, describe: Other pain: (yes.J}JJ9.-Jfyes, describe (Pain scale 1-J 0): ){ U) Nausea/vomiting(� If yes, describe: 'd..h�.J,. a.roo " n.ru·-rflAJ t1JI\Al-H1,tY\a ·, rJ'f\ '1 I \I u \.j Cough/SOB: y� I no )If yes, describe: \,\' Urinaiy Symptoiiis:yes J no )Ifyes, describe: I I I .j WeigbdI\)(1)/jl\ l{,llV....U BP:/'? Uf'\'7 02 Sat: R; 0) T: '1 5(. rl-- P: L--1 Speech slurred: yes / no Alert & Oriented x 3:ry� / DO Jfno, descdbe: Skin :,No�/ pale/ flushed/jaundiced/ diaphoretic Skin temperature (Col� hot waml normal): Heart (RRR, ifno describe): (-<.....I<. j-,(... Lung sounds (bila�: f11 /lV" Oxygen use: yes �o IJyes, amount: Abdomen: Normal: (yes 4 no Ifno, descn"be: LastBM: I I l --,n/1� Bowel sounds; fes fn6" Descn'be ifabnormal Last stool (Color, consistency): NOJJl:IJ), lfnot, describe: \j\Ja.¾{J/\ A Incontinence of� yes/no ,,) Self-void: y._esj'no Foley: yaj f_no) Wound type: � «\ Drasing type(desc:n"be): Size (in cm): �' \ V\ Location ofwouna: "-}I \C\ �of Infection: yes/ no If yes, descnl>e: \1 \ Drainage {amt/color): \.J\ � Hand/Arm stJcngth (Ifapplicable): J.'nnal\ veJ/ no Ifno describe: Leg strength (If applicable): Equal:( yey'/ no Ifno, descnl>e: Pedal pulses (If applicable): Equal: yes/ no lfno, descn"be: Edema: yes'{ no) 'f--\ '--"' IV location: N I ti Type/Rate of IV solution (ifapplicable): \ # ofhours at current IV site (not> 72 hours): Condition ofIV site: \\l "\ Hunger Strike: yes A.._60 )If yes, complete next 2 rows. Room checked for food by security? yes I no Is 1/D/R drinking H2O? yes/ no Ifno, when was the last H2O �DSWDed?: Amt:N Last caJoric intake: Date: t..) I-Pr- Time: .\Cl- Type: •tv. )'AComments: I )Fi-. C) \"') ri'C\d ()Jt\.t C ('\J\r\ ')Pl Yv2i • I \I d\ A:11 p l'\I\� --t-r\ �r\c ('\ f'r\-e.o\ � ,-., -� :'.! :' I~"�-.I"'-' ( AI •'t"X - f("tf) \{./ )4 l 1 d\ '.+fn ()-\· --h Vv\ D \ ' 1J\ t (>"\rift - l ffeJO rs q - 14' l\JU - ..,,�-cc tJ� ( t\J\ td I� µrt, f\JI� t.J\ . P+ E: l I rm,(" -- I (Y\-t\ Y\\J..L 4-1'\ f'<\"t'x\, -t--n'r, T--_f\ - r� 1 Y-11 n .o 11 I ' b)(6);(b)(7)(C) l NURSE'S SIGNATURE/STAMP AND DATE d - -Ht11 ti�, . - 142.6 ?JII, S/J I, J/13, 6114, 2/IS 2020-ICLl-00006 238 C The GEO Group. Inc. I Inmate Name: Alcohol/Drug Withdrawal Monitoring Sheet I Date: Inmate#: I DOB: I Facility Name: Time: Weakness Restlessness Sweating Shakiness Muscle Twitching Anxiety (Reported) BP (Sitting/ Standing) Pulse (Sitting/ Standing) Respiration Rate �� � � � � � � !� � � � � � � � Temperature (watch for hyperthermia) Ataxia (Observed) Drowsiness Vomiting R- Reported 0-0bserved Nausea Nystagmus Confusion Slurred Speech Insomnia Seizure Anorexia Staffs Initials *Documentation will be completed at least twice daily* **The Flow Sheet will be completed for a minimum of three (3) days** ***If significant issues are found, notify clinician and document in health record*** Rev. 7/10, 5/1 I HS-104 2020-ICLl-00006 239 680 .......... lfle. MEDICAL OBSERVATION NURSING PROGRESS RECORD FACILITY: Date/J'ime 11/J.Jy/1-:r �(;. Inmate/Detainee/Resident (I/DIR) Name: �� N\ ,· IVl; ALLERGIES: __ I(tir tvVj.t:'i V d I I/DIR : # f.l_A_�_;_A_______ I DOB: , J.1, V 7 (J /ss Chest pain: yes //ng)lfyes,describe: Abdominal pain: yes ('DJYlfyes,descn"be: Other pain: yes Ji(ho)lfyes,describe (Pain scale �-10): , ... Nausca/vomiting'ye�/noifyes,describe: Cl/) Nc,,.,IAL,U,. \/41r-1.,1d'f,,,u,,v�d' Cough/SOB: yes roo_>Ifyes,describe: Urinaiy Symptoms: yes 1/ho) If yes,describe: 0) T: 48 ,'if P: R: J 'l BP: 12ft I'J'� 02 Sat.:cf'Zh Weight: Speech slurred: yes L-im:::> Alert & Oriented x 3: Aei:/ no Ifno,descn"be: "nnnnA I); Skin INO� I pale/ flushed/jaundiced/ diaphoretic Skin t (Cold, b,..t. Heart(R3R. ifno describe): Oxygen use: yes,r;{Jo Jfyes,amount: Lung sounds (bilaterally): C,1,e;:,v Abdomen: Normal.i1Ye}/ no Ifno,describe: Last BM: I I / 13 J ;';/Bowel sounds:A"""CJ.hio Descn"be if abnormal s.e rve.c:J, Last stool appearance (Color, consistency): Normal,Ifnot,describe: !Joi:- l'fh �.:-. Incontinence ofurine: yeshfo, Foley: yes/tfcc, Self-voi�/ no Wound type: N�"'-"<-Dressing type (describe): � Siz.e (in cm):.,,e::::' Location ofwound: � 9/ - /11°1\.R. n Drainage (amt/color): Signs ofInfection: yes� If yes,descn"be: Hand/Arm strength (If applicable): no Ifno describe: Leg strength (If applicable): Equal� no If no,descn"be: Edema: yes Kno1 Pedal pulses (If applicable): Equal� no Ifno,describe: IV location: � Type/Rate ofIV solution (ifapplicable): M /Aof hours at current IV site (not> 72 hours): Condition ofIV site:/.};r # next 2 rows. Room checked for food by security?� Hwiger Strike: yes� If yes, complete / no Is 1/D/R drinking H20Yyes') no Ifno,when was the last H20 consumed?: Amt: 5-Z, Last caloric intake: Date: // /24-//JJ ime: J:ru-e Type: J:;p,,v,./ .,,,er- Equa]:A/ -'/4 A: NURSE'S SIGNATURE/STAMP AND DATE (_ (b)(6);(b)(7)(C) ?.JIJ, 5/JJ, J/13, 6/14. 2/15 HS-142.6 2020-ICLl-00006 240 MEDICAL OBSERVATION NURSING PROGRESS RECORD FAC1LITY: ____________ ALLERGIES: ___ ______ ___ Date/Time : I/D I �!'.l-73�9 IR# Inmate/Detainee/Resident (I/DIR) Name: I< �'n VG"( �(lm.'m; S) rn ty, Pl�· h"E r-J (Ja..,(l �ut,J I I f� Lung sounds (bilaterally): -f' 1� G v 02 Sat: Gf i = �1 , t1S-3 11M '-' Weight: � Speech slumd: yes 1,116') Skin : Normal /pale /jl�/jaundiced/diaphoretic Oxygen use: yes /prtJ Ifyes, amount: Abdomen: Normal: fesJno lfno, describe: Bowel sounds: yesJ no Describe ifabnormal Las t BM: r ,1, Last stool appearance (Color, consistency): Nonna!, Jf not, describe: f\,o + ol:,JerLt.-.:-,J Incontinence ofurine: yes I no Self-void: y,r;y no , Foley: yes l;DOJ Wound type?' Dressing type (descnoe): lP ( Location ofwound: Drainage (amtJcolor): 'fl 1 )- Su.e(in cm): (1j Signs ofInfection: yes I.fl&\ lfyes, describe: (:]: Hand/Arm strength (Jfapplicable): �: yes/no Ifno describe: Leg strength (If applicable): Equal: �/no Jfno, descnoe: Pedal pulses (Ifapplicable): Equal: 'ftSJ no Ifno, describe: Edema: yes/no IV location: (:7 Type/Rate ofIV solution (if applicable): # ofhom at current IV site (not> 72 hours): Condition ofIV site: (_j) Hunger Strike: yes/no Jfyes, complete next 2 rows. Room checked for food by security? yes/no Is IR drinlcing H20? @ no Ifno, when was the last H20 consumed?: J Q. 3u I/D Amt: !Jo V/4 Last caloric intake: Date: Time: lf?,o Type: 1 u n-d'l. -� Comments: A: P+E: / CL,�eke J ii,� U,./<,i .5,1ns vna .5 19() s, · '"� � � th s.sesJ ctttL: cv. P«-1 n asses.s fn..e..J1.t 1vte n.J- an..d Jt'a,/ 1? <1 I ••A 4/)J.. (b)(6);(b)(7)(C) NURSE'S SIGNATURE/STAMP AND DATE (_ l "'Ill, .Sill, 1/13, 6114, 2115 I{ ')..5/ t}-o /?HS-142.6 2020-ICLl-00006 241 ( MEDICAL OBSERVATION NURSING PROGRESS RECORD ( FACILITY: Date/rune "I 2.i-/r=r tioo .ftvc:� - 0-C-c) Inmate/DetainedResident (I/DIR) Name: 5c:, m irvl I J(c-. � v- ALLERGIES:____:./Y_K-ft_.;.....____ ____ i / I/DIR #: )'2. 't 3 2.<'1/ <"ii DOB: 1/,3/.s� Chest pain: yes //ni)) Ifyes, describe: AbdominaJ pain: yes /('Db.,lfyes, describe: Other pain: yes /(pg) Ifyes, describe (Pain scale 1 -J 0): Nausea/vomiting: yes/ no Ifyes, describe: Nr,. vo..ua V Cough/SOB: yes !f,io) Jfyes, describe: Urinary Symptoms: yes /fJo) Ifyes, describe: R: J� BP: (025/?if 02 Sat: Cf1 Weight: 0) T: '-( !J • ') P: 15 2-. Speech slurred: yes /tfjo� Alert & Oriented x 3: �CSJ/ no Ifno, describe: ' ,....... Skin tCIJIDCT8ture (Cold, bot,� mormaJ): Skin I pale/ flushed/jaundiced/ diaphoretic Heart(RRR;' ifno describe): ----Oxygen use: yes@ If yes, amount: Lung sounds (bilaterally): ("'J e,wAbdomen: Normal�/no Ifno, descn"be: Last BM: ///22--/ IT Bowel sounds: (yer / DO Descnl>e ifabnonnal Last stool appearance (Color, consistency): Normal, Ifnot, desc:ribe: /1.k.,u. ��'""',....J lnc:ontinence ofurine: yes /,ffl>) Foley: yes/ f(ir) Self-void:�_)' no Wound type: � Dressing type1desc:n'be): ,,,0 Size (in cm):,_..eLocation ofwound: ,Y Drainage (amt/c:olor): _Jf3Signs of Infection: yes / no If yes, descn"be� Hand/Arm strength (lfapplic:able): Equal:�/ no Ifno desc:n'be: Leg strength (If applicable): Equal:@/ no Ifno, descnl>e: Edema: yes / pcj") Pedal pulses (If applicable): Equal: ;ftsJ>no lfno, desc:nl>e: IV location: � Type/Rate ofIV solution (ifapplicable): � # of hours at current IV site (not> 72 hours): CCondition ofIV site: ff Hunger Strike: yes /,a;) Ifyes, complete next 2 rows. Room checked for food by security?(Yej / no Is I/DIR drinking H20? fetj no Jfuo, when was the last H20 consumed?: Amt: SC)� fJ Last caloric intake: Date: I/ /2-2,,f/;ff°ime: /"}--r>-CJ Type: D,Y1n.ef ·7v (NorirJJJI I { V I NURSE'S SIGNATURE/STAMP AND DATE l 'VJJ, 5/) I, )/13, 6/14, 2/15 V (b)(6);(b)(7)(C) _J------- ·L_ __ ___ 2020-ICLl-00006 242 HS-142.6 .,I The GEO GrCIIIII, Inc. MEDICAL OBSERVATION NURSING PROGRESS RECORD FACILITY: ___________ ALLERGIES: ____________ Inmate Name: 5a..n, ,' m ; , I< a hll ye. ✓ Date/rime DOB S) r-...... Mr.,I,..,; Yl #'J.IJ.1-31-9 ,� r: I P: 1-c: / Alert & Oriented x 3: f./e) / no Ifno. describe: Speech slurred: yes/ no Skin temperature (Cold, hot, warm)nonnaJ): Skin : Nonnal / pale / !flushed)/ jaundiced / diaphoretic Heart (RRR. ifno d�be): Lung sounds (bilaterally): -cte." ✓ Oxygen use: yes /�o)Jfyes, amount: Abdomen: Nonna!: �no Ifno, describe: Bowel sounds: y� no Describe ifabnormal Last BM: \ 1\ I�\ 11... Last stool appearance (Color, consistency): Normal, If not, describe: Self-void: y�/ no Foley: yes /@ Incontinence ofurine: yes //po) Dressing type (describe): tfj Wound type: t1> Siu (in.cm): Location ofwound: t._:p Drainage (amt./color): l-1) Signs oflnfection: yes� If yes, describe: Hand/Ann strength (If applicable): Equal:@/ no lfno describe: Leg strength Ofapplicable): Equal: 5/ej}/ no If no, describe: Pedal pulses (If applicable): Equal: nil no If no, describe: Edema: yes tfio) Type/Rate ofIV solution (if applicable): IV l ocation: Cl) tn # ofhours at current IV site (not> 72 hours): Condition ofIV site: _ l'T) Hunger Strike: yes lfpoJ If yes, complete next 2 rows. Room checked for food by security? yes I no Is inmate drinking H20? Jes)/ no Ifno, when was the last H20 consumed?: 1 b <..f u Last caloric intake: Date: \ 1I 1'6" I Time: \ b �"'a Amt: i+-o 1/, Type: J) ,' �..£. ( \ti_£ c....,l ,\-"> +-,, I.!. 4" .l l e5� rvtA.J'\ .-4A) \.) 1 l.,, I � ,q 'V)", L�\.L C I <-e. d J-z> e <"T '.S".S l:!.iJ MC:. r1 + -\J1 .\«.( ..S;9YU CV\'lCI� P) � ea..d .+o . - ,n- - Ir b)(6);(b)(7)(C) i ,./ l 'i NURSE'S SIGNATIJRE/STAMPAND DATE Rev. 2/11, S/11 I '+ HS-142.6 2020-ICLl-00006 243 , Subject ID: 359887663 ORDER TO DETAIN OR RELEASE ALIEN ' 10: (NAME and TITLE r:l Person In Charged Facility) OIC, (Name of Facility)��.� u anDnDi. Please I!) Detain Release Agel Dated Birth(Mo.Day.Yr.) 01/03/1953 Nature of Proceedings NTA REMARKS: IN SlgnatureofOIIJcerAuthorizingActton (b)(6);(b)(7)(C) F-- li'AC. ,..,... 1>nn,n no Named Allen SAJa MI, kAMYAR 64 �J7 · Date I 11/17/2017 Sex Nationality I M :IRAN I I Fl le�2 918 Event No:DEN1811000321 Foreign AddANIS None Tehran, IRAN ISlanaluraafOfllt!a-Raceivi g Allen r 1l(b)(6);(b)(7)(C) : FINS: 1238805650 MC-1 CRIM OUT Tide DO Office DBN/DBN UNITED STATES DEPARTMENT OF HOMELAND SECURITY 2020-ICLl-00006 244 Time 12i00 All Section IV- Medication Mngmt, Immunization Testing, Infirmary and Medical Observation Immunization, TB and Syphilis Testing Record Keep on Person (KOP) Medication Sign-out Sheet Keep on Person (KOP) Agreement Receipt for Therapeutic/Soft Shoes Acknowledgment of Responsibility for Care/Storage of Meds Drug Exception Request for Utilization of Non Formulary Drugs Medication Administration Record (MAR) Form HS-138 HS-146 HS-144 HS-131.1 HS-898 HS-236 HS-156 Hospital Tab Medical Observation/Infirmary Rules and Regulations Medical Observation Nursing Progress Records All notes while they are housed in the GEO Medical Rooms HS142.3 HS 142.6 2020-ICLl-00006 245 Immunization, Tuberculosis, and Syphilis Testing Record JNMATE/DET. I/DIR DOB: A22732918 I/DIR#: SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: TUBERCULIN SKIN TEST Co-signed by Physician Facility Aurora ICE Processing Center . O(iilsnostlc reports Jnd consults are dated and signed by oro11lder Abnormal diagnostic reports are addrel.Sed by provider In 0r0111us oote Name, 008, fO II and fadllty name on all pages Nursing protocols are complete and all blanks are fl/led In Special .diets are CO'Slgned by MO All errors are corrected with one fine through, date. Initial and error written _NKDA Is written out on problem 11st (BOP only). Allergles listed on all cllnlcal sheets and on front of chart PPD templeted within 12 hours of Intake and Annually or)(. Rav Cllrrent Preventive Health Care completed within 6 months of arrival. 12/2014 2020-ICLl-00006 264 Section I Master Problems List ICE Health Services Health Summary for Classification ICE Health Service Corps- Medical Psychiatric Alert Form Food Service/Barber Shop Work Clearance Advance Directive, Living Will, DNR Order Authorization for Release of Information Consent Tab Refusal of Health Services Consent to Medical Interpretation Consent for psychotropic medications Consent for immunizations Consent to Medical Service Procedures Consent to Treatment with lnterferon-Ribavirin Consent for Abortion Referral Consent to Medical and Mental Services HS-150 HS-132 IHSC FORM 834 HS-148 HS-106 HS-172 HS-117 HS-190, 190.1-190.9 HS-914, 134,187,187.1, 921,187.2, 130.4 HS-120, 121 HS-920 HS-103 HS-118 Insurance Tab Treatment Authorization Request (TAR) Approved Med-PAR 2020-ICLl-00006 265 HS-210 ( A2213291s SAMIMI, KAMYAR TI DOB: 1/3/1953 Arrival Date: Vu1K UUtl: ( ASTER PROBLEM LIST IRAN Nation: 16:00 ) 2017 11/17/ NAME: FACILITY: ALLERGIES: Aurora ICE Processing Center MAJOR PROBLEMS: (require follow-up as may sif!,nificant/y affect health) Date Problem Number I I 1-:r Ir+ 11 I 1-- I ,·i, Rev 1105, 1/13, 2/15 I '/-- -�D-ci�� Gf [')ruq w;}Ldrnw� \ 2020-ICLl-00006 266 Initials Inactive Date 'Y< fr) 'Rrr> HS-150 ( 11mmffl:J 1MM4 l�ffl ICE Health Service Corps Medical/Psychiatric Alert The detainee named on this form has been examined and presents lhe following problem(s): 0 D D □ D D D Psychiatric Medical Other Detainee should be cleared medically before being removed by ERO. Detainee may require a medical escort if transported. Detainee is pregnant. Detainee is ----- months pregnant. e Oth r: __________________________________ Remarks: ------------------------------------------_.., Stamp/Printed Name Date Provider Signature A22732918 last Name. A#: ·--- SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: Firnt Name: Nation: IRAN t--•• 11/17/2017 16:00 - Country of Origin: Date of Camp Arrival (DCA): DOB: Medical Clinic: Sex: !HSC Form 834 01/2011 Page 1 of 1 cq 2020-ICLl-00006 267 ( 680 ttie GEO G·roup, Inc. Health Summary for Classification A22732918 1/D/R ID# SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: 1. !RA N Nation: 11/17/2017 16:00 $- Facility Name Aurora ICE Processing Center B. Row Assignment (check one): 1. No restrictions A. Bunk Assignment (check one): 1. No restrictions 'f}_ t- 2. Ground floor only Work Assignment/Restriction (check all that apply): __ 14. No repetitive use of hands I. No work restrictions 15. Do not assign to medical __ 2. Medically restricted no work 3. 4-hour work restriction 16. Limit work in direct sunlight to< ____ 4. 4-hour-limited work restriction 17. Limit work when temp. is> ______ 5. Excuse from school 18. Limit work when temp. is< ______ 6. Limit standing to < 19. Limit chemical exposure 7. No walking> 8. No lifting> __ 20. No work requiring safety boots yards __ 21. No work around machines with moving parts pounds 22. Limit work exposure to loud noises 9. No bending at waist __ I0. No repetitive squatting 23. Limit work requiring complex instructions __ 1 I. No climbing 24. Sedentary work only 25. Other: ------------- __ 12. Limit sitting to< ____ ------------27. Other: ------------26. Other: 13. No food service III. DOB .M __ 2. Lower bunk only II. Sex X- IV. Transport Process: Disciplinary Process: ;{_ 1. No restrictions 2. Medical representative required I. No Restrictions 2. EMS Ambulance 3. Wheelchair Yan 3. Mental health representative required 4. Van b)(6);(b}{7)(C) :signature/Stamp of Healthcare Provider Date Rev. 06/14 HS-132 2020-ICLl-00006 268 n.. GIO a,..., Inc. Autorizaci6n para divulgar/obtener informaci6n de salud protegida ! (1) Autorizo a (2) OResumen de alta medica Aurora ICE Processing Center a Hospital/Agencia/Persona O Personal de alta medica O divulgar OEvaluaci6n psiquiatrica Oobtener O d1vulgar y obtener O Historia clinica OHistoria social y examen fisico O Evaluaciones OPlanes de 0rdenes de ________ Tipo especifico medicos tratamiento/habilitaci6n ORegistros de administraci6n medica O0bservaciones de progreso Planes de conducta O Consultas OLaboratorio/RayosX OOtro __ ___________ Fotografias O Revision def paciente Resumen de registros O O Relacionados con la atenci6n de la persona indicada abajo a partir de FE CHA (o INTER VAL0 DE FE CHAS): __________ __ Nombre (Apellido, Apodo: ______________ Nombre) Fecha de nacimiento: _____ Ultimos 4 digitos del numero del seguro social (NSS) Apodo: ______________ O □ (4) (5) (6) O Uso personal O Continuidad de la atenci6n medica OTransferencia/Colocaci6n O Finanzas/Beneficios O0tro _______ __ O Fallecimiento OAbogado O Leyestatal{Tribunal La lnformaci6n se puede dlvulgar/obtener de las siguientes maneras: Por correspondencia, en persona, por telefono, por correo electr6nico o por fax (para necesldades urgentes o de emergencla}. Para los fines de: Restricciones, silos hubiere:_______________________________________ □ D Divulgar a 0btenerde Nombre Nombre Direcci6n Direcci6n Ciudad, estado, c6diqo postal Ciudad, estado, c6digo postal Esta autonzacl6n es valida hasta la fecha calendano: (7 ) Comprendo que la agencia/instalaci6n/persona autorizada mencionada anteriormente que recibira esta informaci6n posee el derecho de (8 ) inspeccionar y realizar copias de la informaci6n divulgada. Asimismo, comprendo que si la entidad que recibe esta informacl6n no es un proveedor/plan de atenci6n medica cubierto por las normas de privacidad de la HIPAA, la lnformaci6n descrita anterlormente puede ser dlvulgada nuevamente y dejar de estar protegida por las normas de la HIPAA. Entiendo que puedo revocar esta autorizaci6n. Sin embargo, la revocaci6n debe realizarse por escrito y debe ser enviada/entregada al (9) departamento de registros de la instalaci6n. Comprendo que ninguna revocaci6n de la presente autorizaci6n sera efectiva para evitar la divulgaci6n de registros y comunicaciones en tanto no la reclba la persona autorlzada de otro mode a dlvulgar reglstros y comunicaciones. Comprendo plenamente que los registros y las comunicaclones a divulgar INCLUIRAN lnformaci6n confidencial come, por ejemplo, evaluaci6n, (10) informaci6n sobre habilitaci6n/tratamiento para salud mental, discapacidades de desarrollo, uso/abuso de alcohol o sustancias o VIH/SIDA, a menos que se marquen especificamente a continuaci6n para su exclusi6n. O Salud mental Discapacidadesde desarrollo O Abuso de alcohol/sustancias OVIH/SIDA O0tro (11) --- ------------ --------- (12) ___________ _ ___ Firma def tutor (menores de 18 aiios o Feeha/Hora Firma de la persona (o Representante Fecha/Hora personal) discapacitados) O Testigo 0 (el segundo progenitor/tutor, si la custodia es compartida, puede firmar aqui) (14) Firma del miembro del personal que divulga/obtiene informaci6n Fecha/Hora Fecha/Hora: ______ Se documentara informacl6n espedflca sobre las divulgaclones y feehas en el reglstro de atencl6n m�dlca de la persona. Un facsimile de este documento original tendra la mlsma validez y efecto que el original. las Normas de Privacidad para la lnformaci6n de Salud de ldentificacl6n Personal, C6digo de Reglamentaciones Federates (Code of Federal Regulations, CFR} 45, Partes 160 y 164, lndican que la lnformaci6n utilizada o divulgada en virtud de la pre1ente autorizaci6n puede estar sujeta a nuevas divulgaciones por parte del receptor de dicha informaci6n. las normas federales de confidencialidad CFR 42, Pa rte 2 prohiben realizar nuevas divulgationes de informaci6n relacionada con drogas o alcohol, a menos que las divulgaciones futuras de esta informacl6n es ten expresamente permitidas por el consentimiento escrito de la persona a la que se refiere o de otro modo se lo permita en CFR 42, Pa rte l. Una a utorizaci6n general para la revelaci6n de informaci6n ml!dica u otro tipo de informaci6n NO restringe ningun uso de la informacl6n para lnvestigaciones o procesamientos penales a pacientes con abuso de alcohol o drogas (52FR21809, 9 de Junio de 1987; 52 FR4 1997, 2 de noviembre de 1987) NOTA: Su negativa a firmar una Autorizaci6n para divulgar/obtener informaci6n no evitar� tratamientos, pagos, ni inscripciones en un plan de salud o su elegibilidad para recibir beneficios 3.3.1 Autorizaci6n para divulgar/obtener informaci6n de salud protegida 04/03 HS-106.1s 2020-ICLl-00006 269 68® n.. 010 ci-..1ric. (1) (2) ( Authorization to Disclose/Obtain Protected Health Information �::�---j to 1 authorize [__··----��:_ora���!;:�� 1 D disclose D obtain D disclose and obtain □ Discharge Summary D Discharge Staffing D Psychiatric Evaluation D Social History D History and Physical □ Treatment/Hab Plans D Assessments ________Specify Type D Physicians Orders □ Med. Administration Records D Progress Notes D Behavioral Plans D Consultations D Lab/X-Ray □ Photos D Record Abstract D Patient Review D Other Concerning thp care of the below named person from DATE (or RA�GE OF DATES): (3) 1/D/R Name: I_ ---··- ···--- --- ---- --···· .. ·--- ·--- -------- --····· ···---·--! 1tD/R #: -------------Date of Birth: ________ last 4 of SSN ______ Alias: ______________ (4) For purposes of: D D Personal Use Attorney D D Continuity of Care D State Law/Court D Death Placement Transfer D D Other Financial/Benefits (5) Information may be disclosed/obtained: Mail, In-Person, Phone, E-Mail or by Fax (For UrgenUEmergency Needs}. Restrictions if any: 0 Obtam. From (6) I A22732918 Name Name SAMIMI, KAMYAR --------------------------------------- Address City, State, DOB: 1/3/1953 Arrival Date: Address IRAN ' Nation: 11/17/2017 16:00 City, State, Zip Code J (7) This authorization is valid until calendar date: � (8) I understand that the above-named agency/faciity7person authorized o receive this information has the right to inspect and copy the information disclosed. I further understand that if the entity receiving this information is not a healthcare provider/ plan covered by HIPAA privacy regulations, the information described above may be re-disclosed and no longer protected by the HIPAA Regulations. (9) I understand that I may revoke this authorization; however, the revocation must be in writing and must be senUgiven to the facility record's department. I understand that no revocation of this authorization shall be effective to prevent disclosure of records and communications until it is received by the person otherwise authorized to disclose records and communications. (10) It is my full understanding that the records and communications to be disclosed WILL include sensitive information such as evaluation, habilitation/treatment information for mental health, developmental disabilities, alcohol or substance use/abuse or HIV/AIDs unless specifically checked below for exclusion. □ Alcohol/Substance Abuse (13) □ HIV/AID's Representative) D Mental Health D Developmental Disabilities D Other · r1 ,,��{,;:'--7r.2,--- ---- ------ - ---- -- - -- -- - - __·· -_-- -_-- -_---____J_ ate ime Signature of guardian (Under 18 or Disabled) ------------------------Witness OR (2nd parent/guardian, if co-custodial, may sign here) (14) Signature of staff person disclosing/obtaining information Date/Time ------------- Dateffime Date/Time: Specific information about disclosures and dates shall be documented in the individual's healthcare record A fascimile of this original shall have the same force and effect as the original. i he Standards !or Pnvacy oi Personally identdiable Aeaffh lnlormabon, 45 CFR Parts i60and 164, states that inlormahon used or disclosed pursuant lo this authorization may be subject to a re disclosure by the recipient of the Information. The federal confidentiality Rules 42 CFR Part 2 prohibit making any further disclosure of drug or alcohol information unless further disclosure of this information is expressly permitted by the written consent of the person to whom � pertains or as otherwise permitted by 42 CFR Part 1. A general authorization for the release of medical or other information DOES NOT restrict any use of the information to criminally investioate or orosecute anv alrobol or da12 abuse patient C52EB21809 June 9 1987· 52 EB4 1997 November2 1987) NOTE: Your refusal to sign an Authorization to Disclose/Obtain Information will not prevent treatment, payment, or enrollment in a health plan or elgibilily for benefits 3.3.1 Authorization to Obtain/Disclose Protected Health Information 04/03 HS-106.1 2020-ICLl-00006 270 G0-0 The GfO Group, Im. ( Authorization to Disclose/Obtain Protected Health Information INS RUCTIONS: Authorization to Disclose/Obtain Protected Health lnformat on (1) {2) (3) (4) (5) (6) (7) (8) (9) (10) Identify whether the form will be used to disclose, to obtain or to disclose/obtain (share) information and whom you are authorizing to perform this function. Check the specific information you wish to disclose/obtain. Check only what is the minimum necessary to fulfil! the purpose of disclosure. Enter a service date - if unknown, indicate "last service date" and only checked information from last service dates will be released or obtained. Complete the individual's name, date of birth, social security number and aliases or a maiden name to help correctly identify the individual. Check the purpose or reason why the information needs to be disclosed/obtained. Circle all manners which the information may be disclosed/obtained. If you wish to restrict any of these, please specify. If nothing is specified, all manners of release will be considered authorized. (Information will only be faxed if URGENT.) Complete the name and address of the agency, facility or person to whom you will disclose the information or complete the name and address of the agency, facility or person from whom you are obtaining the information. If you wish it to be phoned or faxed, include area code and numbers. Complete the calendar date (month, day and year) on which this authorization will expire. Information cannot be disclosed/obtained without a specific date of expiration. Self-explanatory. Self-explanatory. Sensitive information will be released/obtained unless you specifically check an exclusion. If no items are checked all information within the patient record is subject to disclosure. NOTE: In accordance with federal and state privacy laws only the following persons shall be entitled to consent in writing to the inspection, copying and/or the release of the individual's protected health information. The individual if they are 12 years of age or older. The parent or guardian of an individual less than 12 years of age (If both parents have co-custody, both individuals must sign - one on line 13, the other on line 14.) The parent or guardian of an individual between the ages of 12 and 17, provided the individual does not object and has signed the authorization. The guardian of a person 18 years of age or older. An attorney or guardian ad litem who represents a minor 12 or older provided the court has entered an order granting this right. (11) (12) (13) (14) 3.3.1 Individual to sign and date here if - age 12 or older or Personal Representative (must provide proof of representation) Parent to sign and date here if Individual is less than 12 years of age or If individual is between 12 and 18 and has signed on line 12 or Guardian to sign here ifIf individual is 18 years of age or older but is legally disabled. You must provide a copy of the Guardianship court order granting you this right. Guardian to sign here if If you are a guardian ad litem or attorney representing a minor 12 or older in any judical or administrative proceeding. You must provide a copy of the court order granting you this right. Witness to sign and date here. All authorizations require a witness signature to attest to the identity of the person entitled to give consent (person signing line 12/13) Line may be used by a co-custodial parent. Staff person disclosing/obtaining information signs here. Specific dates when disclosed/obtained shall be documented in the individual's clinical record and/or the Disclosure Tracking system. Authorization to Obtain/Disclose Protected Health Information 04/03 HS-106.1 2020-ICLl-00006 271 see ( � Ot·O GN>llp, It,(, Autorizaci6n para divulgar/obtener informaci6n de salud protegida INSTRUCCIONES: Autorizaci6n para divulgar/obtener informaci6n de salud protegida (1) (2) (6) (8) (9) (10) NOTA: ldentifique si el formulario sera utilizado para divulgar, obtener o divulgar/obtener (compartir) informaci6n ya quien autoriza para desempenar esta funci6n. Marque la informaci6n especifica que desea divulgar/obtener. Marque solamente lo que es el mfnimo necesario para cumplir con el prop6sito de la divulgaci6n. lngrese una fecha de servicio; si no la conoce, indique la "ultima fecha de servicio" y solamente se revelara u obtendra la informaci6n marcada desde las ultimas fechas de servicio. Complete el nombre, la fecha de nacimiento, el numero del seguro social y los apodos o el apellido de soltera de la persona para ayudar a identificarla correctamente. Marque el prop6sito o motive por el cual se debe divulgar/obtener la informaci6n. Encierre con un circulo todas las formas en las cuales se puede divulgar/obtener la informaci6n. Especifique si desea restringir cualquiera de ellas. Si no especifica nada, se considerara que ha autorizado todas las formas de revelar la informaci6n. (La informaci6n se enviara por fax solamente en casos de URGENCIA). Complete el nombre y la direcci6n de la agenda, instalaci6n o persona a quien divulgara la informaci6n o complete el nombre y la direcci6n de la agencia, instalaci6n o persona de quien obtendra la informaci6n. Si desea que lo Ilamen o le envien faxes, incluya el c6digo de area y los numeros. Complete la fecha calendario (mes, dia y ano) en la cual expirara esta autorizaci6n. No es posible divulgar/obtener informaci6n sin una fecha de expiraci6n. Se sobrentiende. Se sobrentiende. Se revelara/obtendra informaci6n confidencial a menos que usted la marque espedficamente para que sea excluida. Si no marca ningun punto, toda la informacion dentro del registro del paciente quedara sujeta a la divulgacion. Segun las leyes federales y estatales sabre privacidad, solamente las siguientes personas tendran derecho a autorizar por escrito la inspecci6n, copia y/o revelaci6n de la informaci6n de salud protegida de la persona. La persona misma si tiene 12 anos de edad o mas. El progenitor o tutor de una persona menor de 12 anos de edad (si ambos progenitores poseen la custodia compartida, ambas personas deben firmar, una de ellas en la lfnea 13, la otra en la lfnea 14). (11) (12) El progenitor o tutor de una persona entre los 12 y 17 afios de edad, siempre y cuando la persona no presente objeciones y haya firmado la autorizaci6n. El tutor de una persona de 18 anos de edad o mas. Un abogado o tutor ad /item que represente a un menor de 12 afios o mas, siempre y cuando el tribunal haya expedido una orden que otorgue tal derecho. La persona debe firmar y colocar la fecha aquf si tiene 12 afios de edad o mas o el Representante personal (debe proporcionar un comprobante de representaci6n) El progenitor debe firmar y colocar la fecha aqui si: La persona es menor de 12 anos de edad; o si la persona se encuentra entre los 12 y los 18 afios de edad y ha firmado en la linea 12 o el Tutor debe firmar aq\)j si: _ La persona tiene 18 anos de edad o mas pero es discapacitada legalmente. Debe proporcionar una copia de la orden judicial de Tutela que le otorgue tal derecho. El Tutor debe firmar aqui si: Usted es un tutor ad /item o un abogado que representa a un menor de 12 af\os o mas en cualquier proceso judicial o administrativo. Debe proporcionar una copia de la orden judicial que le otorgue tat derecho. El testigo debe firmar y colocar la fecha aqui. Todas las autorizaciones requieren la firma de un testigo para dar fe de la identidad de la persona que ejerce el derecho a otorgar el consentlmiento (persona que firma en las lineas 12/13) La linea puede ser utilizada por uno de los progenitores que ejerza custodia compartida. El miembro del personal que divulga/obtiene informaci6n debe firmar aquf. Las fechas espedficas en que se divulgue/obtenga informaci6n seran documentadas en el registro clinico de la persona y/o el sistema de seguimiento de divulgaciones. 3.3.1 Autorizaci6n para divulgar/obtener informaci6n de salud protegida 04/03 2020-ICLl-00006 272 ( A22732918 SAMIMI, KAMYAR DOB: 1/3/1953 Arrival Date: Ge@ The Gl;O Group, '"' Nation: IRAN 11/17/2017 16:00 Date of Birtb/Fecha de Nacimiento: / / ) 1/D/R #/Numero del Preso: Consent to Medical, Dental, Mental Health Services and Medical Interpretation I acknowledge that the process for obtaining the medical, dental, and psychiatric services offered at this facility has been explained to me both verbally and in writing, and I hereby authorize GEO and the Health Services staff to treat me as may be medically necessary. Consent for Medical Interpretation 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. Consentimiento a los Servicios de Salud Medico, Dental, y Mental Reconozco que el proceso para obtener los servicios meclicos, dentales, y psiquiatricos ofrecidos en este centro se me ha explicado tanto verbalmente como por escrito. Autorizo a GEO y el personal de Servicios de Salud que me provean el tratamiento medico necesario. Consentimiento de Interpretacion Medica Reconozco que necesito un interprete para hablar de mi condici6n medica. Yo autorizo al personal de Servicios de Salud que comparta informaci6n confidencial con el interprete en un esfuerzo para explicarme completamente mi condici6n medica. Entiendo que el interprete ha acordado mantener confidencial toda mi informaci6n medica. b)(6);(b)(7)(C) Date reso 1�)(6),(b) ll [I :r- [ut 1---' Date/Time :start Member s S1gnature7Stamp 1/D/R UNABLE/ UNWILLING TO SIGN Witness' Signature Date Staff Member's Signature/Stamp Date/Time Rev 6/14, 5/16 2020-ICLl-00006 273 HS- I 18 :::>130 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-396984 Reported: Dec-02-2017 11:22:04 Incident Location Address : 3130 N OAKLAND ST Place Name: in GEO CORRECTIONS DETENTION City : AURORA District: 1 Beat: 3 Grid: 2D2 Telephone no. : 361-6612 General Information Report number: Case Type: FIRE ASSIST Priority: 1 Dispatch : Dec-02-2017 11:22:27 At Scene : Dec-02-2017 11:26:58 How call received : 911 SYSTEM Unit ids: #1 - 105 #2 - 108 #3 - 106 Call taker ID : 309635 Complainant Information Name : l(b)(6);(b)(7)(C) City : 2 State: CO Home Telephone : 303 361-6612 Remarks: Dec-02-2017 11:22:04 - Problem: 2ND HAND INFO PTY NEEDS MED TRANSPORT 40-year-old, Male, Conscious, Breathing. ProQA Urgent Message: ****ALL 2ND HAND INFO - UNKN MED -JUST NEEDS TRANSPORT ----- The caller knows where he is: IN MED AREA - AFR NEEDS TO GO TO BACK GATE ----- No special circumstances. ----- He appears to be completely awake (alert). ----- The caller was too fa (at cad05) on 2017-12-02 11:15:49 - Problem: 2ND HAND INFO - PTY NEEDS MED TRANSPORT (at cad05) on 2017-12-02 11:15:49 - 40-year-old, Male, Conscious, Breathing. (at cad05) on 2017-12-02 11:15:49 - ProQA Urgent Message: ****ALL 2ND HAND INFO - UNKN MED -JUST NEEDS TRANSPORT (at cad05) on 2017-12-02 11:15:49 - ----- The caller knows where he is: IN MED AREA - AFR NEEDS TO GO TO BACK GATE (at cad05) on 2017-12-02 11:15:49 - ----- No special circumstances. (at cad05) on 2017-12-02 11:15:49 - ----- He For: 314407 Monday December 11, 2017 Page: 1 of 3 2020-ICLl-00006 274 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-396984 Reported: Dec-02-2017 11:22:04 appears tobe completely awake (alert). (at cad05) on 2017-12-02 11:15:49 - ----- The caller was too far away to hear if the patient was talking/crying. (at cad05) on 2017-12-02 11:15:49 - ----- He is lying down now. (at cad05) on 2017-12-02 11:15:49 - ----- He is moving. (at cad05) on 2017-12-02 11:15:49 - ----- The caller willbe able to direct the emergency crew to the patient. (at cadintl) on 2017-12-02 11:15:51 - **LOI search completed at 12/02/17 11:15:51 (at cad05) on 2017-12-02 11:16:00 - ProQA Urgent Message: PT IS W/ MED STAFF (at cad03) on 2017-12-02 11:16:03 - ** Recommended unit PE3 for requirement ENGINEALS (>0.2 mi) (at cad03) on 2017-12-02 11:16:03 - **No recommendation for requirement CFO 61 or CFO 62 or CFO 63 or SABLE or SMF (at cad05) on 2017-12-02 11:16:31 - NFI (at cad0l) on 2017-12-02 11:21:50 - pe3 - cor-0 (at cad0l) on 2017-12-02 11:22:09 - **LOI information for Event # Fl7052112 was viewed at: 12/02/17 11:22:09 (at cad0l) on 2017-12-02 11:22:09 - **>>>>by: Staci L. Marcus on terminal: cad0l (at cad0l) on 2017-12-02 11:22:15 - **LOI information for Event # Fl7052112 was viewed at: 12/02/17 11:22:15 (at cad0l) on 2017-12-02 11:22:15 - **>>>>by: Staci L. Marcus on terminal: cad0l For: 314407 Monday December 11, 2017 Page: 2 of 3 2020-ICLl-00006 275 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-396984 Reported: Dec-02-2017 11:22:04 Clea rance Information Fina l Ca se typ e : Cancel - No Units Dispatched Re p ort exp e cted: No Founded: Yes DispatchDeta ils Unit number: 105 Disoatched: Dec-02-201711:22:27 Officer 1: 315181 -�bl(6l;(bl(7J(C) Enroute : Dec-02-201711:22:47 At scene: Dec-02-201711:32:47 Cleared: Dec-02-201711:38:52 Dispatcher ID: 315629 I Unit number: 108 Disoatched: Dec-02-201711:23:04 Officer 1 : 315184 -¥bl(6);(b)(7)(Cl I Enroute : Dec-02-201711:23:08 Cleared: Dec-02-201711:23:17 Dispatcher ID: 315629 Unit number: 106 Dispatched : Dec-02-201711:23:13 Officer 1 : 301038 {b)(6);(b)(7)(C) I Enroute: Dec-02-201711:23:19 At scene: Dec-02-201711:26:58 Cleared: Dec-02-201711:43:04 Dispatcher ID : 315629 Unit number: 103 Dispatched: Dec-02-201711:33:10 Officer 1 : 301024 - �b)(6);(b)(7)(Cl Enroute: Dec-02-201711:33:13 Cleared: Dec-02-201711:37:31 Dispatcher ID : 315629 I Unitnumber: CR3 Dispatched: Dec-02-201711:33:11 Officer 1: 18566 -�bl(6l;(bl(7J(C) I Cleared: Dec-02-201711:36:51 Dispatcher ID : 315629 Unit/Office rDeta ils ** END OF HARDCOPY ** For: 314407 Monday December 11, 2017 Page: 3 of 3 2020-ICLl-00006 276 AURORA POLICE DEPARTMENT CAD CALL HARDCOPY CP 2017-397093 Reported: Dec-02-2017 13:12:04 Incident Location Address : 3130 N OAKLAND ST Place Name : in GEO CORRECTIONS DETENTION City : AURORA District : 1 Beat : 3 Grid : 2D2 General Information Report number: Case Type : INFORMATION Priority : 4 Cleared : Dec-02-2017 13:12:04 How call received : TELEPHONE Call taker ID : 248910 Complainant Information Name : BROOKE ADAMS COUNTY City : 2 State : CO Remarks : Dec-02-2017 13:12:04 - WANTED INFO ON PARTY TRANSPORTED AT 1140, ADV'D HER THIS IS FEDERAL FACILITY AND TO CONTACT FEDS (at cad03) on 2017-12-02 13:12:04 - WANTED INFO ON PARTY TRANSPORTED AT 1140, ADV'D HER THIS IS FEDERAL FACILITY AND TO CONTACT FEDS Clearance Information Remarks : E911 CALL UNFOUNDED Final Case type : HANGUP/UNFOUNDED/CANCELED Report expected : No Founded : Yes Reporting Officer! : 248910 Dispatch Details Unit/Officer Details ** END OF HARDCOPY ** For: 314407 Monday December 11, 2017 Page: 1 of 1 2020-ICLl-00006 277 UCH Rightfax Serverl 12/4/2017 6:04:52 PM PAGE l/015 Fax Server University of Colorado Hospital Health lnforrnat1on Mgrnt 12605 E 16th Avenue Aurora, CO 80045 0 720-848-1031 F 720-848-5551 Communication Date: 12/4/17 To: Geo Group,lnc Attn: GEO GROUP.INC Fax: 303-341-2652 Phone: 303�(b)(6);(b)(7)(C) I From: l(b)(6);(b)(7)(C) I UGH Health Information Management fained in or attached to this fax message is privileged and confidential information, in or Tile m If the reader of this message is not the i 1ent, or the employee or the use of the individual(s n · no ified that any disclosure. dissemination, agent responsible to deliver it to the intende re y prohibited. If you 1 distribution or copying of this communi is communication in error, please nmediately by telephone and return the original documents to us y , PLEASE CALL THE SENDER BACK IF YOU RECEIVED THIS FAX IN ERROR. 2020-ICLl-00006 278 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE Patient Information R11r.P. Qrh"r Karnyar. Sarnimi PI1one ACICl[e&s �1lk1l0Wtl 222.222-2222 (Home) ,._URORA CO 80010 E1hni�Jry Non·Hi�p11nic Fax Server MRN: 5960219, DOB: 1/3/1953, Sex: M Adm: 12/2/2017. D/C: 12/2/2017 Demo ra hies Palienl Name samimi Karnyar 2/015 - ______,________ ,______ Prnf;,rr;,<1 L11ng1rngia Engli�h Tx Team Encounter Diagnosis ···-·····- .. ..... .............. ,. . Comrnents ••·••·············..··· ••·••·•• ••·••····••·• .... , .................. Not on File Social Histo Num.: Results do not include all patient labs during this encounter. These are all labs from the last 24 hours of the patient admissioni or encounter. Please contact the lab for additional results. Resulted Labs for the last 24 hours of patients admission/encounter. •• No results found for the last 24 hours.•· Current Immunizations No immuni711tinn5 nn f1!P.. Procedures and Imaging No orf1rrtHP.ri A, MD�· 12102117 1203 2 ED CPR PROCEDURE (367071096) 0/(lerea Dy MOlllOOlln, LOii A. MD all 12,04/17 1203 03/03 ....... .... .., ......,.,'.. ,..... .................-.- --� .. Fax Server · · · A�Xl);;r + ype. Pny&i� -�-�---- .........-········ ······-··· Slal11S. Ad(le,,a,Jon i .... .... ..- - - .-, .-.-...-. ... . .-, ....... '............ ..................... ...... ·•-....-..' ........ ·A"ss-es·s:0nie-r.;,t1-P:tan·:·. -· ·. -:··:.-.·. ··•· · .··· · ········.-..·.··.-···.·: ·.··..-.�.-.-..·:..·.-.:·.-··...·..,·:.· ...··....,....·..· :· .···.·.·· .::.-.·:.:··::�·:··:•:•::-;.••: -�:-··: ·--·'•:•.-:.; -:,:-··::·:.:·:::·::•.::•·: .::·.:·.- -.-.- -. P�tient ·• See·�·;·�·'.·c��i� �·��--i��· ·�·i·th·,;·��-;���·;�·�/�·�rbi,(5);(�)(7j(Ci. I see their ��·te for additional details. We were not able to obtain full details on patient s HPI, PMH/PSH, family history, meds/allergies and ROS secondary to patient s condition on arrival. [Unresponsive, cardiac arrest] 64 y.o. male Chief complaint: Cardiac Arrest There were no vitals taken for this visi t. Head:NC,AT Eyes: no erythema, no discharge. Pl1p i ls are 4mm, fixed, and di lated. ENT: nl ext ears, nl ext nose Neck: supple, vomitous in his airway Back: no obvious deformity Pulm Equal breath sounds Card: no carotid pulse, no cardiac activity Abd: soft, NO Ext: NT Neuro: no facial asymmetry lnteg: no diaphoresis. no cyanosis GU: Rectal Exam: no obvious melena IMPRESSION: My different ial diagnoses includes but is not limited to: As above, PLAN: ED COURSE: 11 :43 AM: Pt arr ived to ED by EMS with CPR in progress. 11 :46 AM: Stopped manual CPR, started automatic compressions. 11 :47 AM: I-Gel in place. not breathing spontaneously. Vomitous in his airway, pupils are 4mm, fixed, and di lated. Caroti d pulse now, equal breath sounds. Conjunct i va are pale. Posit i ve color change 11 :49 AM: No carotid pulse. Stopped compressions. 11:50 AM: Continued compressions. 11 :51 AM: Pulse check. no caroti d or femoral pulses 11 :53 AM: Pulse check: no carotid, no cardiac activity 11 :55 AM: Pulse check. ContinL1ed asystole/PEA with no palpable pulses. 11 :58 AM: Pulse check: No pulse, will resume CPR. 12:00 PM: Pulse check: back i n asystole, no carotid or femoral pulse. No cardiac movement on US Will Printed by 5172 at 12/4/17 2:41 PM Page 3 2020-ICLl-00006 280 UCH RightFax Server! 12/4/2017 6:04:52 PM AMC EMERGENCY �r. �-°--·�-r���.�.�•:.�.?�-��.. °.. PAGE 4/015 Karnya,, Sarnimi MRN: 5960219, DOB 1/3/1953, Sex M Adm: 12/2/2017. D/C: 12/2/2017 r,,,�.". 3.w_ �,. � _ri·-�·..� 3.'. 1.�'..�!.��.1.!..�.�.:�.� .�r.1. (�� .i�.��.�). ······ .. . .. . .. . . .. . .. ..... ........ . 1 1 o Fax Server tlt __ ,._ ........................... ·•·•····........... ............. ········· ..... resume CPR. 12:02 PM: Called time of death after 35 minutes of CPR. 12 10 PM Called coroner to discuss pl s case. 12:27 PM: Labs: Trop 0.08, Chem with na 126, bicarb 15. glc 416, er 1.8 12:38 PM: I reviewed the paperwork from Aurora Detention Center and he went to the medical center there for "withdrawal, suicide watch, dehydration, NN". 1:00 PM: Adams County coroner called back and will transfer jurisdiction to Arapahoe and requested that the body be put on coroner s hold. 1: 13 PM: Adams County called back and verifed that he was at a federal facility. Detention Center is speaking to staff now for a disposition plan. Staff notes we can transfer body to morgue on a coroner s hold. They ask that we place brown bags on the hands. Addend: Trap 0.08, Chem with na 126, bicarb 15, glc 416, er 1.8 Cili◊t C<>mpl<1im: P1..)ift�fit t->n:stn,��; �Y!H: • Cardiac Arrest HPI Samimi Kamyar is a 64 y.o. male who was BIB EMS with unknown PMHx who presents to the ED today initially for vomiting in his jail cell. When EMS arrived. they noticed blood in his vomit. He was in a prone position on EMS arrival and they saw that he was not breathing well on his own, probably breathing about 2 breaths per minutes, with very little movement Pt was warm to the touch and EMS started compressions. EMS reported that at the call for them was received at 11: 17 AM this morning, pt was apparently vomiting and moving. EMS arrived on scene and initiated ACLS @ 11 :25a as pt had stopped breathing. EMS performed compressions for approximately 19 minutes PTA. Pt has been down for roughly 22 minutes total. EMS gave pt three rounds of epi PTA. Pt went into A Fib at one point which was when EMS shocked him x1. No past medical history on file. No past surgical history on file. No family history on file. S<>i.:i,1! i·Usiwy �t.ff)�hH•)·r:.e U:�t.'., T!.'lp:( r":i • Smoking status: • Smokeless tobacco: • Alcohol use Not on file Not on file Not on file Review of Systems Unable to obtain ROS 2/2 cardiac arrest. There were no vitals taken for this visit. Physical Exam Page 4 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 281 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 5/015 Fax Server Kamyar, Samim, MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017, 0/C: 12/2/2017 Prior to procedure, hands were washed and sanitary- conditions observed. Intubation Date/Time: 12/2/2017 11 :47 AM Performed byJb)(6);(b)(7)(C) Authorized by!._ _ Corisent: The procedure was performed in an emergent situation. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Ti me out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, ---,-----e--- equipment, support staff and site/side marked as required. Indications: respiratory failure Intubation method: direct Patient status: unconscious Preoxygenation: BVM Pretreatment medications: none Laryngoscope size: Mac 4 Tube size: 7.5 mm Tube type: cuffed Number of attempts: 1 Cricoid pressure: no Cords visualized: yes Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector Breath sounds: equal Cuff inflated: yes ETT to lip: 24 crn Tube secured with ETT holder Patient tolerance of procedure: Intubation performed during cardiac arrest. Time of death ultimately called. CPR Date/Time: 12/4/2017 12:03 PM Performed by: (b)(6);(b)(7)(C) j Authorized by�_---------� Consent: The procedure was performed in an emergent situation Verbal consent not obtained. Written consent not obtained. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: anonymous protocol, patient vented/unresponsive Local anesthesia used: no Anesthesia: Local anesthesia used: no Sedation: Patient sedated: no Comments: CPR x 20min DEATH note: Date and time of pronouncement 12 2 17, 12:02pm I Pronouncing physician name:l(b)(6);(b)( 7)(C) Attending physician signing the death certificate: deferred to coroner Date and time of coroner notification: 12: 1 Op Page 5 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 282 UCH RightFax Serverl 12/4/2017 6:04:52 PM PAGE AMC EMERGENCY 6/015 Fax Server Karnyar. Sarnirni MRN: 5960219, DOB: 1/3/1953, Sex: M Adm: 12/2/2017. 0/C: 12/2/2017 �.'?..�.��.V. �.e.r..�.�,.��..�K--��.".�.�.�.".�! .��.r�. �:.�.?...�!..�.���!.��-1.!.� �. :�.�.��. 1�.��1.i�.���.>. ............. .................... . ...... . .. . . .. . . . . . i .. . .. ...... ... . .. . .... . . .. .. . . ..... .. .. ... .... ......... . .. . . .. .. . . .. .. . Coroner investigator s name: see paperwork w/decedent affairs Coroner instructions: may move body to the morgue in a body bag, put brown bags on the hands, body is on a coroner s hold. I at_te_s_·t_ t_h at tt1is documentation !·1as been prepared under the ; ) <7)(C) By signing my name below, 1J.... (b -:; ,.. b)(6);(b)(7)(C) == ;= == == == ======L .:... � direction and in tl,e resence o� I . b)(6);(b)(7)(C) 12/02/17 12:32 PM A�H.ij�hs£Ait�'.$fitiP:ifE?/<:\/:?: : //:\:\:/\:::'.:-::::':'.'::://-:: :::::i'.':2: /T\:\\:/7?:::::: :>_.::-:·:-::-:-•o:-:-:--::.:.:•:·•· ··· ..:..: ·:: /.::/:/::··::':':· ·:·· I have personally seen and examined this patient. I have fully participated in the care of this patient. I agree with all pertinent and available clinical information. including history, physical exam. assessment and plan as documented by the resident and/or advanced practice provider, except as noted . I have reviewed the pertinent and available documentation by nursing. EMS and ancillary staff. except as noted . I reviewed previous records for this patient: Yes: Epic Records Medical screening exam performed . I, rb)(6);(b)(?)(C) I personally performed the services described in this documentation. All medical record entries made by the scribe were at my direction and in my presence. l have reviewed the chart and discharge instructions (if applicable) and agree that the record reflects my personal performance and is accL1rate and complete . fb)(6);(b)(7)(C) 112/02/17. 12:32 PM I personally supervised the following procedures:lntubation, cpr. kb)(6);(b)(7)(C) 12/02/17 1550 l(b)(6);(b)(7)(C) 12/04/17 1202 l(b)(6);(b)(7)(C) 12/04/17 1206 12017 12:14 PM Elc(;!lu11i(;ctlly :;iy11ccJ L, b)(6);(b)(7)(C) !201i 12:33 PM El<.:(;IIOlli(;ctlly :;iy11ccJ L, 1::017 12:40 PM Eln.lrnllic.Rlly sign�(1 h ,::017 12:41 >'M EIP.r.tronic.Rlly signf'<1 h 12017 12.46 PM Eleclronii:.111y $i,1ne<1 b 12017 1,00 PM EleClf0lliC:llly $i(1nevi e. . . . . .. .. . . . . . .S!/111_ . . . . . . . .. . ...... .. • ..... ............ . ... ...!3<,<•.h.':... ...... .. ... .• ..•..12/21201 .7.1.2:41_.l''M.. . .............. ............ . .. ......... >!i'l'.'· • . .•. .. . . ..,.... . . ...... . . ... .... . . ..........-. ..• .. .. ... ..1 ?.!212Q1 .7 14.40 f.'.M ... ............ .. . . . !3Cfi1.. >e . .. . . ...... . . ... ... .... . . ............. .... S�J.11.... . .......... . ........ .......... .. .... ............ ... ... ..•.. ..1.. ?/1!.?91.7 .. 12:3.3.. P.M. . .. ... ....... ....... .... . . ... .. . Soih=60 L AMC Lab ml/min/1.73 "square meters" Comment: Component Sodium POC 00,.,.. ,..,, eGFR estimated by IOMS-traceable MORD Study equation for ages 18-70 years Not validated for use during Printed by 5172 at ·12/4/17 2:41 PM Page 9 2020-ICLl-00006 286 UCH RightFax Server! 12/4/2017 6:04:52 PM PAGE AMC EMERGENCY pregnancy, acute illness, or 10/015 Fax Server Karnyar. Sarnimi MRN: 5960219, DOB: 1/3/1953. Sex: M Adm: 12/2/2017. DIC: 12/2/2017 in peo ple with unique diets or abno rmal muscle mass. POCT eGFR African American 49 >=60 mUmin/1. 73 "square meters" Comment: AMC Lab L eGFR estimated by !OMS-traceable MORD Study equation fo r ages 18-70 years . Not validated fo r use during pregnancy, acute illness, or in peo ple with unique diets or abnormal muscle mass. Anion Gap POC '••· • ,.., • ' ' •· ••• ••• •••••• ••• • ' , . , '" •• '" '" • ' -�• •• ·''"'"''' •• •••• ••••••••• ••••" •• Testing Performed By Lab -Abbreviati o n 233 -AMC Lab 22 ;.•• •" ••· ••· ••• ••• V' ••• • ••• ••• •• Director Name ANSCHUTZ MEDICAL CAMPUS LAB, AURORA, CO (b)(6); (b)(7)(C) rn - 20 rnmol/L •·. ••· ••• •· '•" •• •• • • ''" ,, . POCT I STAT Chem 8 + [367071084] Electronically si ned b (b)(6);(b)(7)(C on 12/02/17 1211 Ordering user: (b)(6);(b)(7)( 12/02/17 1211 Ordering mode: Standard ••• • · ,,,,, .. ••• •• Address 12401 East '17th Avenue Campus Box A022 AURORA CO 80045 Order ,,.,, •• AMC Lab ••· • · • •••v• •• · •• ••• • ••• •• ;.•• ••• ••• , .. , .. , •••• Valid Date Range 05/03/16 1239-Present � . . .. ':. .. · POCT I STAT Chem 8 -t [POC2138] (Order 367071084) · -------� Status: Completed Authorized by: l(b)(6);(b)(7)(C) I POCT I STAT Chem 8 + Results Status: Final result (Collected: 12/2/2017 12:06) Abnormal POCT I STAT Chem 8 + [367071084) (Abnormal) Filed by: Lab, Backgro und User 12/02/17 1211 Result details Specimen Info rmatio n Type Com H ••• ••·•••••• ••• •••••• • Source Blood Resulted: ·t 2/02/17 1211, Result status: Final result Resulting lab: ANSCHUTZ MEDICAL CAMPUS LAB, AURORA, CO Collected On 12/02/"I 7 1206 o nents Reference Flag Value Lab Range Component 126 L 133-145 AMC Lab Sodium POC ... ,,. .,... ,....., ,__ . .. .. mmol/L...... ... ,... ....,... , ..,. ..... ... . ,.........., .............. .......,...,......,.. ......................... ""... ,.•. , .. .. . ..,. ... .....,.. .... .. ...... ,....... ,. ... .,.....,...,..... .,...,,.... ,...,.. ,..... _.,...,... ,...............,.. ,....,__. ., Potassium. POC.. ... . _.... . . . . . ....,.... . __. . . . .. ...... 3. . 5 .... .. ..... . .. ......3.5. • .5.1.. mmol/L. . .. - ..... ....... .. ... ..... AMC.Lab. ............ .... .. 93 98 - 108 rnrnol/L L Chloride POC AMC Lab .. . . . . . . ..... ..... ....1-. 5....... .....,....,..,... ,... ,... 21,.-.. 31.., mmol/L..,. ,... , L.. .... w., .. ............,.....,.,...,.•. AMC Jab . ,__. ..... ....... ,...,..,... , ....... . ,. TC 02 Venous.. POC.... ..... ... .... ......... ....... ........ 419...... .. . . . .....7-0.. :J.��.JlJQ/9.L. ... Ji.... ... . .......... . ....�ry,�_J{l.t;l ..... .. . ...... . . .. Q L\!9.9§�. pgg_. 7-25 rng/dL BUN POC H 83 AMC Lab w ..........w.• W• ..... ... .. .. ..... . ..... . . . . . . . . ..... . . .... Page 10 Printed by 5172 at 12/4/17 2 41 PM 2020-ICLl-00006 287 UCH RightFax Server! 12/4/2017 6:04:52 PM ucbeaitb-- AMC EMERGENCY -- _cre_aJipine POC . . . POCT eGFR Non African American 1.8 40 Comment: PAGE 11/015 Fax Server Karnyar, Sarnimi MRN: 5960219, DOB. 1/3/1953, Sex: M Adm: 12/2/2017, DIC: 12/2/2017 _0. 7 - 1.3 rn!=JI�!>=60 ml/min/1. 73 "square meter s" H L .... AMC Laq . AMC Lab eGFR estimated by !OMS-traceable MORD Study equation for ages 18-70 years. Not validated for use during pregnancy, acute illness, or in people w,th unique diets or abnormal muscle mass. POCT eGFR African American 49 Comment: >=60 ml/min/1. 73 "square meters" L AMC Lab eGFR estimated by !OMS-traceable MORD Study equation for ages 18-70 years. Not validated for use during pregnancy, acute illness. or in people with unique diets or abnormal muscle mass. Anion Gap POC Testing Performed By Lab - Abbreviation 233 -AMC Lab 22 Name ANSCHUTZ MEDICAL CAMPUS LAB, AURORA, CO Director (b)(6);(b)(7)(C) AMC Lab Address 12401 East 17th Avenue Campus Box A022 AURORA CO 80045 INTUBATION Valid Date Rang e 05/03/16 1239- Present Status: Edited Result - FINAL (Resulted: 12/2/2017 11 :45) Results Resulted: 12/02/17 1145, Result status: Edited INTUBATION 367071082 Result - FINAL Filed by: b)(6);(b)(7)(C) 12/02/17 12/04/17 1206 Ordering provider: (b)(6);(b)(?)(C) 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL - AURORA, CO Narrative: Montagna, Lori A. MD 12/4/2017 12:06 PM Intubation Date/Time: 12/2/201711:47 AM Performed by: (b)(6);(b)(7)(C) Authorized by. '---�-----,,---,......... Consent: The proce ure was per orrned in an emergent situation. Required items: required blood products, implants, devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Indications: respiratory failure Intubation method. direct Patient status: unconscious Preoxygenation: BVM Page 11 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 288 UCH RightFax Server! 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 12/015 Fax Server Kamyar. Sarnimi MRN: 5960219, DOB. 1/3/1953, Sex: M Adm: 12/2/2017, D/C: 12/2/2017 Pretreatment medications: none Laryngoscope size: Mac 4 Tube size: 7 .5 mm Tube type: cuffed Number of attempts: 1 Cricoid pressure: no Cords visualized: yes Post-procedure assessment: chest rise, ETCO2 monitor and CO2 detector Breath sounds: equal Cuff inflated: yes ETT to lip: 24 cm Tube secured with: ETT holder Patient tolerance of procedure: Intubation performed during cardiac arrest. Time of death ultimately called. Testing Performed By Lab - Abbreviation 69 - Unknown Name UNIVERSITY OF COLORADO HOSPITAL­ AURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 Order Valid Date Range 04/03/14 1716- Present INTUBATION [PRO89) (Order 367071082) Electronically Si ned b : b)(6);(b)(7)(C) on 12/02/17 1203 ..,....,..,..,,,....,,�..,.,,..,.--�S�f..,, !l\US: Completed (b)(6);(b)(?)(C) 12/02/17 1203 Ordering user: (b)(6) ;(b)(7)(C) Ordering provider: l�--,------� ] Authorized by: (b)(6);(b)(7)(C) Ordering mode : Standard Order comments: This order was created via procedure documentation INTUBATION Status: Edited Result - FINAL (Resulted: 12/2/2017 11 :45) Results Resulted: 12/02/17 1145, Result status: Edited INTUBATION 367071082 Result - FINAL 12/02/17 Ordering provider: (b)(5);(b)(?)(C) Filed by: b)(6);(b)(7)(C) 12/04/17 1206 1203 Resulting lab: UNIVERSITY OF COLORADO Result details HOSPITAL - AURORA, CO Narrative: Montagna. Lori A. MO 12/4/2017 12:06 PM Intubation Date/Time 12/2/2017 11:47 AM Performed by. b)(6);(b)(7 )(C)____ __ ►.. "'!" � ""! ""! '!": � '!'!"! __,. (C) Authorized by b)(6);(b)(7) .__ ___,, __. Consent: The procedure was performed in an emergent situation. Required items: required blood products, implants. devices, and special equipment available Patient identity confirmed: arm band Time out: Immediately prior to procedure a "time out" was called to verify the correct patient. procedure, equipment, support staff and site/side marked as required. _____ _ Printed by 5172 at 12/4/17 2.41 PM Page 12 2020-ICLl-00006 289 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 13/015 Fax Server Karnyar. Sarnim, MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017. DIC: 12/2/2017 Indications: respiratory failure Intubation method: direct Patient status: unconscious Preoxygenation: BVM Pretreatment medications: none Laryngoscope size. Mac 4 Tube size 7.5 mm Tube type: cuffed Number of attempts: 1 Cricoid pressure no Cords visualized: yes Post-procedure assessment: chest rise, ETC02 monitor and CO2 detector Breath sounds: equal Cuff inflated yes ETT to lip: 24 cm Tube secured will): ETT 11older Patient tolerance of procedure: Intubation performed during cardiac arrest. Tune of death ultimately called. Test,ng Performed By Lab - Abbreviat,on 69 - Unknown Narne UNIVERSITY OF COLORADO HOSPITALAURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 ED CPR PROCEDURE Valid Date Range 04/03/14 1716 - Present Status: Final result (Resulted: 12/2/2017 11 :45) Results Resulted: 12/02/17 1145, Result status: Final ED CPR PROCEDURE 367071096 result 12/04/1 7 Ordering provider: b)(6);(b)(7)(C) Filed by b)(6);(b)(7)(C) 2/04/1 7 1206 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL -AURORA, CO Narrative: �b)(6);(b)(7)(C) ! 12/4/2017 12:06 PM CPR Date/Time: 12/4/2017 12:03 PM Performed by: b)(6);(b)(7)(C) � Authorized by:l.._--------Consent: The proceclure was perfonnecl in an emergent situation. Verbal consent not obtained. Written consent not obtained. Required items: required blood products. implants, devices, and special equipment available Patient identity confirmed: anonymous protocol. patient vented/unresponsive Local anesthesia used no Anesthesia: Local anesthesia used no Printed by 5172 at ·12/4/17 2.41 PM Page 13 2020-ICLl-00006 290 UCH RightFax Serverl 12/4/2017 6:04:52 PM AMC EMERGENCY PAGE 14/015 Fax Server Karnyar. Samimi MRN: 5960219, DOB 1/3/1953, Sex: M Adm: 12/2/2017. DIC: 12/2/2017 Sedation: Patient seclated: no Comments: CPR x 20min Testing Performed By Lab - Abbreviation 69 - Unknown Name UNIVERSITY OF COLORADO HOSPITAL­ AURORA, CO Director Unknown Address 1635 NORTH AURORA CT AURORA CO 80045 Order Valid Date Range 04/03/14 1716 - Present ED CPR PROCEDURE [EO2031] (Order 367071096) 367071096 on 12/04/17 1203 Electronically si ned b (b)(6);(b)(7)(C) Si ius: Completed 12/04/17 1203 Ordering provider: �l(b)( Ordering user: (b)(6);(b)(7 )(C) _ B_ )_;(b_)(_ ?)(_ C_)_____r Ordering mode: Standard --� Authorized by: '- -,-�-,-. -=:This order was created via procedure documentation Order comments: ED CPR PROCEDURE Status: Final result Results (Resulted: 12/2/2017 11 :45) Resulted: ·12102117 1145, Result status: Final ED CPR PROCEDURE 367071096 result 12/04/1 7 12/04/17 1206 Filed by b)(6);(b)(7)(C) Ordering provider. (b)(B);(b)(?)(C) 1203 Result details Resulting lab: UNIVERSITY OF COLORADO HOSPITAL - AURORA, CO Narrative: l(b)(6);(b)(7)(C ) I 12/4/2017 12:06 PM CPR Date/Time: 12/4/2017 12:03 P M Performed by:l(b)(6);(b)(7)(C) Authorized by '----,-------:-----:-' Consent: The procedure was performed in an emergent situation. Verbal consent not obtained. Written consent not obtained. Required items: required blood products. implants, devices, and special equipment available Patient identity confirmed: anonymous protocol, patient vented/unresponsive Local anesthesia used: no AnestMsia: Local anesthesia used: no Seclation: Patient sedated: no Comments: CPR x 20min Page 14 Printed by 5172 at 12/4/17 2:41 PM 2020-ICLl-00006 291 UCH RightFax Server! 12/4/2017 6:04:52 PM uctJeal:tb---Testing Performed By Lab - Abbreviation 69 - Unknown AMC EMERGENCY Name UNIVERSITY OF COLORADO HOSPITAL· AURORA, CO Director Unknown ------------------__ ,___ _ , _ U U_O -• --•,_, • 1.---�-tl1111111 fltt, .. 11:•H♦ttl I PAGE 15/015 Fax Server Karnyar, Sarnim1 MRN: 5960219, DOB. 1/3/1953, Sex: M Adm: 12/212017. DIC: 12/2/2017 Address 1635 NORTH AURORA CT AURORA CO 80045 Valid Date Range 04/03/14 1716- Present ------------♦-PH _______ END OF REPORT ---- Page ·15 Printed by 5172 at 12/4/17 2.41 PM 2020-ICLl-00006 292 12/04/2017 (FAX) 11: 46 Fa I k ' Falt« . . . :-. . .. . ...... .. . Date: /J- 'l-11 FAX COVER SHEET FOR FALCK ROCKY MOUNTAIN b){6);(b){7){C) Attention ;_::(b)(:_;., 6)::.;!..;(be-=)(7)("""" C,--) __--1---------, F rom: --=---=::--::::::-= :-------:::::: --:;;;--r-;: - -: �3 �a � 0 � i' �:--'_ Fax NuLmber · · Regarding Claim #: ______ Number of pages including cover sheet:� Claims Department: Falck Rocky Mountain -NPI 1528446820 TAX ID 473265252 Billing Office Address: ----=-�=---, >;(_ci_____ FAX# 480-912-7565 ...) ""-·- 2020-ICLl-00006 293 P.001/006 (FAX) 11:46Falk 12/04/2017 ■ FINAL P.002/006 ame Patient Care Report ini Falck 12/0212017 Date of Service: Run#: 47787 Falck Rocky Mountain AFR#: Dest Fae MR#: 5960219 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 ___,I I....__R_E_S_P_ O_N_ S_E--'IN_F_O__....,I ._I ____D_IS_P _O_S_IT_ IO_N___�I ,.__I __ TlM=E S--,-:-.,,....,..-' lnjwy: 11:15 12-02-17 Dutlnatlo1< Anschutz lnpaUanl Pavilion Locallon: 3130 N OAKLAND ST RE '----�C.;.; F�O__ .;.;_;.;.IN ;;;;;W ;.;. Unit 0646 Vthlclo: 108 Doc'd By. !(b)(6):(b)(7 )(C ) .;.;;.:.;; .;:;_ AUROOA, __, CO 80010 UNK PROBLEM (PERSON OOWN) STANDING, SITTING, MOVING. OR TALKING Locn Type Prison Nrtu,eOR:alt ! {AIP) 12fi05 E16TH AVE Aurora, Adams, CO 80045 Twooflorvlcc S'8na Response Cond al Out.: Unchanged Dool Rooao« Closest Appropriate FecUlty Rosp.w llh: AFR Englne3 Lo•el of 1h11 ALS.Paramedlc Unit: Trano. Delay: None'No Delay Deat Delay. None/No Delay Al Scene Mlloa: 0 .1 BSN: 000-00-0001 Mala Belongl"90: Belan9l"9 Loll With: Race : Other c.ncet Albuo: NrModArr. EMS can emp12:16 12--02-11 Pl Mv'd to Prern. . : Sl1'9tcher • P1o Tran•pfct 1 >t Moved from Pram Supine• Caniad, Slretchar Triage Clan.: R8cvDoctor, RHponM Zone: Aurora_BAFB Home Count,y : DOB: 01 /03/19 53 (64 yrs) Waight: 130.00 lb$ 58.97Kgs llraaelow/Luten DLlnfo: nlted Statu HameAddr,: UNKNOWN AURORA.ARAPAHOE, CO 80010 Moblle No.: (303 ) 30�303 MIiiing Addr. Name: Phone: Sex: HomeAddr.: SSN: ;r.:/ 12:16 12-02•17 In .. Samora lo Ce"': None Noted Nona PoH. lnju,y: No Homo : Kamyar Samlnt Ald111L: 11:41 12-02-17 Ou1Tra 11:44 12-02-17 Al DKL MIia: 2.2 Hols,hl ofFall: IP18onSceno: Single Activity at Orwot: Unit Typ• ALS Se1t: S<»n0 Dol•Y: Non&'No Delay RHp.Deley: None/No Delay IIHe Cuualty: No Olhor AQency. Al potion!: 11:21 12-02-17 TraO!Ca..: Tra,.pOlt 11:38 12-02 1- 7 S.ol Po■lt/on, Cr•W3 Lave!: Alocono: 11:19 12-02-17 Trans. PrlorHy. Immediate lights & Siren Protocolo: Crow 1310: Crew.I Rolr. En routo: 11:17 12-02-17 Outcome: Paijent tn,ati,ransport AcultyatDloprtch: I C......, Rolo: Olher PaNenl Caregiver-Al lnlllal Pt. Acuity: Soena, Olhar PaUent Caragl\ler-Transport RHp Priority. Immediate Lights & Siren Crow1 L.,..t EMT.Paramedic Crow#2 IO: l(b)(6);(b)(7)(C) it.cw: 11:16 12-02-17 Dlopotr:lt 11:17 12-02-17 c...wl11D: l(b)(6);( b)(7)(C) Crow2Role: Driver-Response, Drtver-Transport, 0th« Pallenl Caregiver-Al Scene Crowl Lofft EMT- Basic ~· '8.AP; 11:16 1 2"21 7 : 612-02-17 01., Notify: 11 1 NEXT OF KIN Relllllon•lllp : DOB: Celt Phone:: INSURANCE no Insurance lnfonnatlon entered. I TS PATIENT COMPLAN Chi•( CompteJnt Cardiac Arrest (Primary) 5 Minutes Anatomic Location Page1 of5 2020-ICLl-00006 294 12/04/2017 11: 46 Fa I k ■ Fl NAL P,003/006 (FAX) Patient Care Report Kamva Falck Date of Service: a6ent Name ; j Samini 12/02/2017 Run#: 47787 Falck Rocky Mountain AFR#: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 Chest Ocsansntem Cardiovascular Primary Svmntom CardiacArrest Other Au oehrted Symptom, CardlacArrest Lail PCII Intake MpdtcalttxObblnpdECPm HISTORY Put Mpdfcol History Unresponsive No Known Drug Ale,gy No Known Envtronmanlal/Food Allergies Medications Unresponsive ASSESSMENT PhyslMedlcal/Manlal Limit Req Amb Setvlee Pt. Can1 Rec@ Send Fae ETOtt'Onlg use: Nona Reported I12/02/2011 1:1:24:00 BoclvA,:"H Airway Cln:ulation _ Extemal/Skln Neurological Pdm■rv 1roeress1°o; By; WILSON, RYAN A.1Hfffflln11 IOd Comm,ata Patent Pulses - Carotid • Absenl (0) Normal Nol Done Cardiac Attest BodvAroa At•!l•rn•ots and comments Breathing Absent Mental Slatua Unresponalve Blood/Fluld LO$$ None Noted IMPRESSIONS Page 2 of S 2020-ICLl-00006 295 12/04/2017 ■ FINAL P.004/006 (FAX) 11: 46 Fa I k Patient Care Report Falck r Samini Date of Service: 12102/2017 Run#: 47787 Falck Rocky Mountain AFR #: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 CARDIAC ARREST Cardiac Arrest Yes, Prior to EMS Arrival Armst EHotoav Cardiac (Presumed) ResuscHation Attempted Attempted Defibrillation Arrest w;toesacdby Witnessed by Lay Person EicstMonHored Rhythm Asystole Spontaneous Cir culation Attempted Ventilation Initiated Chest Compressions No 12:00 12-02-11 Resuscltatjon Disc pate/Hme Dlscontlpued Reason Medical Control Order RhythmatPesttnaHon Asystole CPR Types Compressions-Continuous Ventilation-Bag Valve Mask Ti meofcardjac Arrest 2017-12-02 11:19:00 CPR Prov1g,g PrjortoEMS ctct No AED Used Prior to EMS Cara No END OF CARDIAC ARREST EVENT Expired in ED CPR ProvidedBv I First Responder (Fire, Law, EMS) TRAUMA I cause ofIDIYfY Method of Injury - Not Applicable Time fJA le 121212011 11:23 No J Pulse o, Absent; Regular VITAL SIGNS � Monitor Rate Re19jg,tgry O oApne1c, E1 +Vi +Mi" 3 Skin Temp=Nonnal Skin Color-Normal Skin Moisture=Normal Cardiac Rhythm=Asystole Pupil size: Lefl=4-mm, Rlght:4-mm Pupil Reacts: Left:::Non-Reactive, Right=Non-Reactive Level of Consciousness: Unresponsive; Arm Movement: Lefl=None. Right=None; Leg Movement: Left=None, Right=None; Heart Rate Mearuremenr-Palpated Taken by: no trauma scores entered no prior sld entered no treatments entored TRAUMA SCORES PRIOR AID TREATMENT SUMMARY Page 3of S 2020-ICLl-00006 296 11: 46 Fa I k 12/04/2017 ■ Falck FINAL P.005/006 (FAX) Patient Care Report Date of Service: 12/02/2017 Run#: 47787 Falck Rocky Mountain AFR #: 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 Dest Fae MR#: 5960219 NARRATIVE M108 dispatched with E3 for an unknown medical. Arrived on scene to find a 64 yoM lying supine on the ground with CPR in progress by AFD personnel AFO reported the pt still had agonal respirations at a rate of 2 a minute upon their arrival. Pl was in asystole on the monitor. Pt recieved a total of 9 rounds of CPR. Pt remained in asystole uni� the 8th round of CPR. On the 8th rhythm check, the pt was in V. Fib. Pl was shocked once. Upon next rhythm check, the pt was back in asystote. An 10 was placed in the pt's RIGHT tibia. Saline w pressure bag hung. Pt was administered 3 rounds of Epi. Epl was given at 1130, 1134, and 1139. An red OPA was placed. A size 4 Igel was placed. Pt was ventilated with a BVM with 15 LPM of oxygen. Pt's capnography remained arourid 22 throughout transport. No obvious trauma was noted on the pt. Pt was found in a suicide watch room. Pt was in that room after he attempted to hang himself last week. Pt was transported emergent to AIP for further assessment AFO Engine 3 maintained patient care throughout transport. Paramedic R. Wilson MISCELLANEOUS no mlsce/laneov:s entered !lllll 12/02/2017 11 :59 SIGNATURES � Who IIADtd fb)(6);(b)(7)(C) FacMity Acceptance The patient, Kamyar Saminl, was received by this facility on the dale and al the time indicated and this facility furnished care, services or assistance lo the paHent My signature is not an acceptance of financial responsibility for the services rendered. (b)(6);(b)(7)(C) 12/02/2017 15:41 Why Pl11eot did nphlgn Crew • No Patient or Auth Rep Signature Crew Member #1 l(b)(6);(b)(7)(C) CPR In Progress My signature below indicates that, at the lime of service, the patient was physically or mentally incapable of signing, and ttiat none of the patient's authorized representatives were available or willing lo sign on the patient's behalf. My signature, in part authorizes submission of a claim to Medicare, Medicaid, or any other payer for any services provided lo the patient by Falck Rocky Mountain, Inc. My signature is not an acceptance of financial responsibility for the services rendered. (b)(6);(b)(7)(C) CREW INFORMATION ss,o P•lt(Ifrno · � 115 tt!oa 1210212017 09:08 ..,..,="'""..,..=...,..,,..,. =(b 1 )(6) ;(b)(7)(C)-----. Cr:,w1 State IP 0151100 � EMT-Paramedic -'.a:d 202 tDmo .,...,,,.. ..,..,=""',.,... "'"bf )(6),....,.(· b)(7)(C) ---, Crew2 Stal" IP 0161091 EMT-Basic Lim Pacie 4 ors 2020-ICLl-00006 297 12/04/2017 FINAL (FAX) 11:46Falk ■ Patient Care Report Falck 12/02/2011, {". Run#: 47787 . I•:· Date of Service: Falck Rocky Mountain 10703 East Bethany Drive Aurora, Colorado 80014 (720) 857-7000 (b)(6);(b)(7)(C) P.006/006 AFR#: Dest Fae MR#: 59 6 I��...� . l. •�" 021 ! .i \. ·J' (b)(6);(b)(7)(C) X=========-- ·• :,= ·, : j. ! ,: Peqe 5 of5 2020-ICLl-00006 298 AURORA FIRE RESCUE INCIDENT REPORT REQUEST Send request via email to flre@auroragov.org: or via fax to 303-326-8986; or bring In person or mall to: Aurora Fire Rescue 15151 E Alameda Pkwy, Suite 4100 Aurora, CO 80012 Please note: It may take up to 5 days to process your request. Today's date: _1_2/_1_1_/2_0_1_7______ (b)(6);(b)(?)(C) Requester Information Name: lL. ________ Address: 3130 N. Oakland St. __J----- (b)(6);(b)(7)(C) Phone#: !=-l ======--......,......,......_______ City: Aurora State: CO Zip: 80010 -=-=-------''----------------------------- Relationship to Incident ICE Supervisor VaIid ID# (Only needed if requesting medical information) Requested lnfonnation (Check report needed) Ia Fire Motor Vehicle Accident 5 Requester signature: (b)( );(b)(?)(C) � Patient I Medical � Other EMS Resoonse L------------------------:=-----:-:-;: ::::::::;:::=.=::::;:::::;;:::======---------, _ Emaili �l..;;.L.. b 6 · b 7 c _______, 11:29:00 Eoioeobdoe 1·1 CJOO, 1 mg 10 Authorization Type: Protocol (standing order) Administered bYl(b)(6) (b)(7)(CJ Q ________ ��� J 11:30:00 BP: Absent; P: Absent; Monitor Heart Rate: O· R: Absent; ETCO2: 26; GCS: 1 +1+1 =3· ECG: AED: ECG Inter retation Method: Interpretation by Asystole; ECG Interpreted By (bl/6l:/bH7l(Cl b)(6);(b)(7)(C) EMS Provider; MOEX0; Position: Supine; Taken y: '----�------' 11:32:00 BP: Absent; P: Absent; MonitQc Heact Rate· O· R· Absent ETCO2: 24; GCS: 1+1 +1 •3; ECG: AED: J ECG Interpretation Method: Interpretation by Asystole; ECG Interpreted Byfbl(5J,(bl (7)(C) EMS Provider; MOEXO; Position: Supine; Taken bY=Kb)(6);(b)(7)(C) J 11:34:00 Epinephrine 1;1 OO, 1 mg 10 Authorization Type: Protocol (standing order) Administered by: (bl(5J;(bl(7J(C) QO fb)(6);(b)(7)(C) j 11:37:00 BP: Absent; P: Absent; Monitor Heart Rate: 0; R: Absent; ETCO2: 18; GCS: 1+1+1=3; ECG: AED: Asystole; ECG Interpreted By: kbl/6\ /b\/7\/C\ t ECG Interpretation Method: Interpretation by EMS Provider; MOEXO; Position: Supine; Taken bYjsamtol , Kamyac 2020-ICLl-00006 303 II Page 4 of 5 Aurora Fire Department- EMS Patient Care Report No patient documents collected. Report authored by: l(bl(6l;(b)(?)(Cl 2020-ICLl-00006 304 Page 5 of 5 The GEO GROUP, INC. AURORA I.C.E. PROCESSING CE TER SUPERVISOR SUPPLEMENT AL REPORT CASE NUMBER ..J Supervisor's Name (print) I Time Date L)uty Assignrncm ·- 1110 12/02/2017 Watch Commander fb)(6);(b)(7)(C) Supervisor's Action(s) and Summary: On theabove date ?Dd timti(b)(6);(b)(7)(C ) lcalled me to medical. When I arrived j(b)(5);(b)(7)(C) I was standing with the door open :1t cell door 527. Cell 527 was the cell wh r ainee Samimi, Kayar 22732918 was being housed for a level one suicide watch, and(b)(5);(b)(7)(C) was the assigned Officer. Whl'n got to the door Wll� I looked down on the floor and detainee Samimi was lying on a mattress on his right side. I lookt'd at the detainee and his e s was open and he looked pale. I asked what was going on whl're "as the stated he went to call the doctor. I thought he looked retty bad and nc·td nurse. (b)(6l;(b)(7)(C) f he nas calling to go the emergency room. I went into the nurse's station and asked (b)(6);(b)(7)(C) for an ambulance and he said that be was calling (b)(5);(b)(7)(C) for permission and that he called I stated that we needed an him twice and had no answer so now he was calling (b)(6);(b)(7)(C) so I went to the phone in front ambulance now. At that time he was talking to b)(6);(b)(7)(C) to call 911 and get an amhulance nurse's station and at 1110 hours I told Control (b)(6);(b)(7)( C) sent here to the facility emergency. I then went back to cell 527 where detainee Samimi was lying on the floor. He was breathing and moving around he was covered in barf and sali\'a and I could also see blood. I told him to try to lay still that an ambulance was coming. He acknowledge JU{' h_v looking at me. I then told the Officer to stand by for the paramedics and that I was going to the armory to hand out wea ons to the transport officer that will go with the ambulance as escort. Officer b)(6);(b)(7)(C) After issuing them there weapons, I returned to medical where• when I arrived there were about 6 firefighters and paramedics working on detainee Samimi giving I and asked what happen. He told me that he was breathing him CPR. I looked atl(b)(6);(b)(7)(C) when the paramedics arrived then all of a sudden he stop breathing. I then went to the phones and called Warden Choate, AW (���? and (b)(6);(b)(7)(C) . I then escorted the paramedics out to the ambulance. The ambulance eparted to University Hospital Emergency Room at 1136 hours. All required personal notified. EOR Recommendation(s): Forced Used: 0 YES 181 NO Explain: 181 NO Type: Restraints Used: 0 YES Time Applied Justification: X6l;�l�XCJ Signature: J Date: 2020-ICLl-00006 305 12-02-1?- General Incident Report The ,·GEO Group, Inc. -Auro.ra/LC.E. Processing Center Subject:· Frease dr«kono ofthe app,op,iatt> boB$ El 0 0 □. �,tty Breach Major At9 Med. Emetp«1Cy Contnabaod O Rules Vlofatfon 0 M/norlh O Maintenance D Hmw«-Stdb .,......____,__ 0 � Od.aln#on O«alnee Assault 0 □ SelfHam, □ __,),(alorDlstutbance 19"' oth«: '- 5'vt I CA f)/3 0 0 Detalnet1 on staffAssault DetalnH ln/UI')' lllnorDlnur6ance t1Jk[Ct1: Date: Pi;c. o:i.,, 2-01 7 Time: //.' oo Location: . ,S /111 CA P1§ /;r/-'r1?:,f/ _£2-,7 Detainee: '°' S'� i Mt -, �]'JdZJ?.z.73,2.qig Pf1fH Name sws.27 Detainee: Donn PrtntHMne . : iirint Hime · Details of: ' . · (Pleue-Ptfnt• riclde.nt IOI IDf mien, How& . YouMustSta . . No )(6);(b)(7)(C) 2020-ICLl-00006 306 � Donn General Incident Report □continuation r�·]supptement, The GEO G1·oup, Inc. -Auroru/J.C.E. Processing Ccnkr f Subject: fl/li/Jtco---f' W,1--fcti I Date: Time: / IOO Details of Incident {Continued) (Ploase Print· �. "'1Ja� Mien, Where, How &Mly. You Must State Facts And AbsollJtely No Edlf�llzlng) . . ... .. -·· ..·· . ..:.··· --.•:· . � Supervisor's-Assessment (Continued) . (Please Prtnt and Include: Date/Time, IfAOD 1111S � wt,6f1 and by Kflcm) . . ·£.� 5v:J2-½ U, S Cf\. W u-l--clA (b)(6);(b)(7)(C) '.. (b)(6);(b)(7)(C) J General Incident Report The GEO Group, Inc. -Aurora/LC.E. Processing Center _ Subject:· 1-H ch«:kone oftheapptopdate boxes El. �rftf Breach Major Are Med. Emergency Contrabar>d To: bJ(6J;(blC7lv . , a.�n�. G..Q\!ff2�\ffi�� i;, + ()1\CA.. tMT -�l'Y"\� bi s«fHMm IDf· · Qetalfs· of·fncldent . m.«a, mien,, How& , : □ □ .'27:,3,2C\IC/ $':)., IOf ,,.�. 0 \. Oda/nee on �•lnee Assault 11tle: L, Title: ):> ( o __ . .From1b)(6>;la,r II» ZZl3?'tllf' nt me .Dorm IOI □ □ Date: Location: Detainee: Donn 1.e�7 - • LI� Time: Print Name ID# Dorm Prtnt Name IDf Donn � � · � .. � �-:c � i PrtntName Details of Incident (Please Print - Who, What, When, Whem, How &twly. You Must State Facts And Absolutely No E:dltorlalizJng) _..n I � � d =��� ����J�m r�. l Supervisor's Assessment (Please Print and Include: Dat&IT7me, ff AOD was notified, when and by� � ��� V-i �(I\.. [b)(6);(b)(7)(C) I 'ItajfSignature And Prin:ed Nam:and 7'1tle .r�al t fJi}_ ;;; -,- Report sub � ... l<�><6�(b ; �i)( )( "� l1-i�2-1Z1J?p Supervisor's Signature, Printed Name and 1ilft. Daie And Time 2020-ICLl-00006 309 . ' General Incident Report The GEO Group, Inc. -Aurora/LC.E. Processing Center _ Subject:· Fw.se dltJd(oae d the llpp(Op,iate boxe$ El. □ □. �rftyBreach Major fire Med. Emf!f'IJ«'CY Contraband D Rules Vlolatfon D Mlnorlh □ D Maintenance HungerStdlce Detainee: � i• ktt""y� ·z.:2.:71:). 'fl& Pt'1n1 Name 10, ·: �tHarne IDf □ D D l- r­ C>- 0 Title: lltle: To: CbHB>; .From: (bHB>;(7> 0 /�- I....Ddafnee on D«alnoe Assault ii«tHMm Ma/«' Dlstutt,anoe 0th«: Detainee: Donn j: b)(6);(b)(7)(C) l :. ,. □ Detainee on Staff Assault DetuiH fn/ury MlnorDfstu,t,ance Time: Date: 1 / · o-i . ,-; Location: -h'l� , Jo s-37. .' • .• ' D D • .. . offorce Rq,orUu (b)(B);(b)(l)(C) /I I) t, 2020-ICLl-00006 310 P�Name IOI Donn IOI Donn· aes General Incident Report Aurora Detention Center The GEO� Inc. Su.bject: Plee# check ooe ort11e llPPfOllliat• bates □ �rtty Bl'NCII 0-., []contraband Fire [)M.,nt.n.nce []Minor DiaturbanCe -�nor Firt [JM.Jor Disturbance To:l Fro � S\..,..('1:1'.":VJr I'\.. .f> f< JN-,..-1,- . (b)(6 );(b )(7)(C) 2020-ICLl-00006 311 ----------,-D---Donn -Name (' NarM ID Dorm .. General Incident Report The GEO Group, Inc. -Aurora/1.C.E. Processing Center Subject: Please check one of the appropriate boxes □ Security Breach □ Major Fire W □ Contraband Med. Emergency To: D D D D □ □ □ Rules Violation Minor Fire Maintenance D Hunger Strike (b)(6);(b)(?)(C) From: J Detainee on Detainee Assault Self Harm Ma/or Disturbance Other: D p D Detainee on Staff Assault Detainee Injury Minor Disturbance Date: / Time: �"-"--"'--L--,:_____ Location: b)(6);(b)(?)(C) ! I Do Detainee: Detainee: Print Name Dorm ID# Print Name ID# Dorm Print Name ID# Dorm Supervisor's Assessment (Please Print and Include: Dateffime, If AOD was notffied, whej and by whom) SAL (b )(6);(b)(? )(C) � l:':)' .,..._vf(n .f :vf p � :::,, c!! ·tte:::::d:..:?..:...: ...i....i......:.Y..::;es:::...._.1..1....:....:.::0:.....______ Use of force Re ort subm1 (b)(6);(b)(?)(C) w/L 12�2-1i. Supervisor ·s Signature. Printed Name nd Title. Date And Time 2020-ICLl-00006 312 General Incident Report The GEO Group, Inc. - Aurora/1.C.E. Processing Center Subject: □ □ □ □ Please check one of the appropriate boxes Security Breach Ma/or Fire Med. Emergency Contraband To: �b)(6);(b)(7)(Cl From: l(b)(6);(b)(7)(Cl Detainee: □ □ □ □ I I □ □ □ □ Rules Vlolatlon Minor Fire Maintenance Hunger Strike Detainee on Detainee Assault Self Harm Major Disturbance other: □ □ □ Detainee on Staff Assault Detainee Injury Minor Disturbance Date: 1--;}- :;}- \J Time: 1 l ?:lO Tltle:�N§PoQ;t: Location: � -A v � W: - __ _ _ � �------Title: �tJ.JrE{\{A-� '::>4N I N 1 1 � 'l � d,:l, 3:)qtft,Detalnee: Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Details of Incident (Please Print - Who, What, 1-'Vhen, 1-'Vhere, How &Why. You Must State Facts And Absolutely No Editorializing) 5 7l 01')� �� JU.ANC:>io•s::r !2fEic.hf, �bl( l;(bl( (Cl 6No N"-:\Sc:Lf w:6Us Aovt 5E{) :¼o Al>,M ve .Do "1S? A i'¼QllAl, tEIY\f&bf:;N(\J. 'I. '-AN6 Ar0\)1\J.Q 8AUL TQ e.,\ c& 1 1',J �MQ.v �CGr \t,,, L::r\,! t)G-t:Pr INS6 } ,NS:,c.G ME,O, L £iec .C'E£T w ANO Supervisor's Assessment rv--r� (Please Print and Include: Datemme, if AOD was notified, when and by wflom) >--u- .Sv..�v,� svvi11 tt...�· (b)(6);(b)(7)(C) I • Use of force Re p ort subl,llllll:il.�.L...1....u:�..L..:1::.u.i.J._____� --.12.AN":>Po Staff Signature And Printed Name and Title e._ L....,,-----,---.-..,.,....---,---,..-,-:---r,,.,...----r.o,,,.,..-..r"'"'"':""-:-r.---Supervisor s ignature, 2020-ICLl-00006 313 TRANSPORT/ESCORT LOG l (b)(6);(b)(7)(C) (b)(6);(b)(7)(C) J Escorting Officer(s)_.._ _____ _.____ . (Print Name) (Print Name) _3�0'-------/ .... '1'--'0 Time of Departure ___._I _._ =-______ Time of Return____,\'-- S Vehicle Used: Model L12Jo LJ 9 Make ___,i3_3'-,3J.-_"o_.,S:;;._...:,,Q'---_ Starting Mileage:_ Ending Mileage: 2;>,]C> S: 2} DESCRIPTION OF EVENTS TIME Supervisor Signatur �oW VIHV b)(6) ;(b)(7)(C) �---------',____ Date: Ja-a,- 17 Transport Officer Signature: __________ Date: _________ ORIGINAL: Transportation Lieutenant CC: Business Office :HSA 2020-ICLl-00006 314 General Incident Report Aurora/1.C.E. Processing Center The GEO Group, Int SU bject: Please check one of the appropriate boxes 0 Security Breach 0 Major Fire 0 Minor Fire D Major Disturbance To: b)(6);(b)(7)(C) f From :l(b)(6);(b) (7)(C) I I 0 Rules Violation D Contraband D Maintenance D Minor Disturbance 0 Hunger Strike 0 Self Harm D Detainee Injury Title: t .7, Date: /2--2--/7 Title: Location: /J/e. Detainee: 0 Detainee on Detainee Assault Detainee on Staff Assault �Medical Emergency Other: Time: I 1,.()D Ct,;i,,7/2,()� Detainee: Name ID Dorm Name ID Dorm Detainee: Name ID Dorm Name ID Dorm Detainee: Details of Incident Please Print- who, what, when, where, how, & why. You must state facts (absolutely no editorializing!. OW l'l:.-i.-17 A--r LJ 10 HntAs ,. :r rJ///5 ::r�PP/.n&.tJ (J'I fb)(5);(b)(7)(c) I Tt) �t-l;' -5lfl FoA ,f nRIJ;'C.,f/.. £HR�C.�,,.,,,t,'l... I. C:./JLl-:_ft_l) 9..11 ,4-A--/) /l/)il,f6P 71iB. f2.J/!__/J7(.;f.J� l+T tll'JIPtl�'i 4-11/tQ/I./JI.,r1tl -rM-R- P.#-t,t,,"1'1 IS'/ rt-1-A-1 ','/Ji /v'llR�nl)A tA.1-1BuLB/l-'"c,,11. AT -rlfll f,4.c.,'l:_,'1'f_t te,f/{R /1-7 /3UI,; C-#7611�0 t,v,I,� R< CAJ/11RIJ Pff..R ,· M R.-r h � 0 FP, ' C,f?, /{ f � Fb)(6);(b)(7)(C) I Supervisor's Assessment Please Print and Include: Date/Time, whether AOD was notified, when, and by whom. b)(6 );(b)(7)(C) se of Force Report submitted?: Yes No /J/o Supervisor's Signature, Printed Name and Title, Date & Time Page 1 of 1 2020-ICLl-00006 315 From: Sent: To: Cc: Subject: l(b)(6);(b)(? )(C) 6 Dec 2017 11:10:12 -0500 (b)(6);(b)(7)(C) l l(b)(6);(b)(7)(C) SAMIMI DDR Good morning, I'm writing to request SME assistance for the most recent detainee death. We are tentatively planning to conduct the onsite review at the Aurora Contract Detention Facility the week of January 8, 2018. A summary of the death is below. Thanks! l(b)(6);(b)(?)(C) I ISSUE: On December 2, 2017, ERO Denver reported the death of ICE detainee Kamyar SAMIMI, a 64 year old citizen oflran, at the University of Colorado Medical Center (UCMC) in Aurora, CO. The medical staff at UCMC pronounced SAMIMI dead at 12:02 p.m. MST, with the preliminary cause of death of cardiac arrest. ERO Denver notified the U.S. Department of Homeland Security, Office oflnspector General, and the ICE Office of Professional Responsibility via the Joint Intake Center. ERO Denver Field Office Director has left a voice mail and SMS (text) message with the emergency point of contact identified in SAMIMI's book-in sheet. The FOD will continue to coordinate the notification to the Iranian Interest Section in the Pakistan Embassy located in Washington, DC of SAMIMI's death as well as to SAMIMI's next of kin. All media inquiries will be referred to the ICE Office of Public Affairs. BACKGROUND: On April 19, 1976, the former Immigration and Naturalization Service (INS) admitted SAMIMI into the United States at New York, NY as an F- l non-immigrant student. On May 9, 1979, INS adjusted SAMIMI's status to that of a Lawful Permanent Resident (IR-6) based on his marriage to a US citizen. On October 29, 1985, SAMIMI filed an application for naturalization with INS. On January 9, 1987, INS denied SAMIMI's naturalization application due to lack of prosecution for failing to submit requested documents. 2020-ICLl-00006 316 On June 9, 2005, the Arapahoe District Court in Centennial, CO convicted SAMIMI for the offense of possession of a controlled substance, to wit: cocaine and sentenced him to two years of deferred sentence and 64 hours of community service. On November 17, 2017, ERO Denver arrested SAMIMI at his residence pursuant to his criminal conviction which rendered him removable. On the same date, ERO Denver served SAMIMI a Notice to Appear (NTA) charging removability pursuant to section 237(a)(2)(B)(i) of the Immigration and Nationality Act, as an alien who has been convicted of a control substance violation. On November 21, 2017, the Office of Chief Counsel cleared SAMIMI's NTA for legal sufficiency and subsequently filed it with the Executive Office for Immigration Review in Denver. SAMIMI was pending a court date. On November 28, 2017, the Aurora Contract Detention Facility (ACDF) on-site physician placed SAMIMI on level one suicide watch, requiring 5-minute visual inspection while in the medical isolation unit. This suicide watch was ordered as a result of SAMIMI wrapping a bed sheet over his head and around his neck. The physician ordered the suicide watch until SAMIMI could be evaluated by mental health professionals at the facility. On December 2, 20 I 7, ACDF contract staff and one attending nurse from the GEO medical staff attempted to place SAMIMI in a wheelchair in preparation of a scheduled on-site mental health appointment. SAMIMI could not sit in the wheelchair and was laid back down on the mattress within the medical isolation/suicide watch cell. Just after 11 :00 a.m. MST, SAMIMI began vomiting and the ACDF contract staff contacted emergency medical services (EMS). After he vomited, SAMIMI was placed into a recovery position (on his side) and the vomit was taken out of his mouth. He was breathing and responsive to questions and statements until after EMS arrived at 11:20 a.m. MST. SAMIMI then stopped breathing while EMS was attending to him. EMS began CPR and subsequently transported SAMIMI to UCMC at 11:36 a.m. MST. On December 2, 2017 at 12:02 p.m. MST, medical staff at UCMC declared SAMIMI deceased with a preliminary cause of death of cardiac arrest. On December 2, 2017, at approximately 12:40 p.m. MST, the ICE detention services provider notified ERO Denver that UCMC staff had declared SAMIMI dead. SAMIMI is the first detainee to pass away in ICE custody in fiscal year 2018. 2020-ICLl-00006 317 From: Sent: To: Cc: Subject: Attachments: �b)(6);(b)(7)(C) 7 Dec 2017 19:23:08 +0000 r)(6);(b)(7)(C) Detainee Death Review - Kaymar SAMIMI SAMIMI DDR Info Request Memo.pdf Good Afternoon Sir, OPR/ERAU will be reviewing the death of detainee Kaymar SAMIMI who was detained at the Aurora Contract Detention Facility and who expired on December 2, 2017. In furtherance of our review, I've prepared a preliminary data request, attached. I ask that your office provide the requested materials by December 15, 2017. I understand the turn-around time on the requested information is short, but it's critical that we have time to review the information prior to the onsite interviews. I appreciate your understanding, and thank you in advance for your cooperation and assistance. Please let me know if you have any questions. V/r, (b)(6);(b )(7)(C) nspec I0n an omp iance Specialist Department of Homeland Security U.S. Immigration and Customs Enforcement Office of Professional Res onsibility Office: (202) 732 b)(6);(b)(7)(C) Cell: (202) 271 �---� 2020-ICLl-00006 318 Office of Professional Responsibility U.S. Department of Homeland Security 950 L'Enfant Plaza SW Washington, DC 20536 U.S. Immigration and Customs Enforcement MEMORANDUM FOR: rb)(6);(b )(?)(C) FROM: l(b)(6);(b)(7)(C) SUBJECT: Deputy Field Office Director ICE ERO Denver, Aurora Contract Detention Facility (ACDF) Inspection and Compliance Specialist ICE QPR External Reviews and Analysis Unit __� Information Request for IlCMS Case �(b� >_ <7_> _ Detainee Death Review - Kamyar SAMIMI (A22732918) Summary The ICE Office of Professional Responsibility (OPR), External Reviews and Analysis (ERAU), will review JICMS l - 'l.,, fl\ V ) Immigration Facilities PREA Risk Assessment Ge@ The GEO Group, Inc. Detainee's Name t- :> A- Number -z.91� 2-,, � Lr, ) Current Offense: : (1) Use interview, 213/216 form and all other official documents available to answer the following questions, (2) For items 2, 9, 12, 13 and 18 - a "Yes" response requires a referral to Mental Health Services, (3) A total score of 4 or more (yes) in the "risk of victimization" or 3 or more (yes) in the "risk of abusiveness section also requires referral to Mental Health Services. Each "Yes" answer is worth one (1) point. AT RISK OF VICTIMIZATION � 1. Have you ever been approached for sex/threatened with sexual assault while incarcerated? 2. Have you ever been the victim of sexual assault? 3. Do you have any reason to fear placement in general population? 4. Younger or elderly detainee (/=65) 5. Small physical stature (men: <5'6" and < 120 lbs.) (women: < 5'0" and < 118 lbs.) 6. Does the detainee have a developmental/mental/physical disability? Yes No - - - 7. Do you wish to identify as Lesbian, Gay, Bisexual, Transgender, lntersex, or Gender Nonconforming? o Yes □ No Is the detainee Perceived to be Gender Nonconformin ? □ Yes □ No 8. First-time offender 9. Criminal history of sex offenses with adult/child victims 10. History of consensual sex while incarcerated (add 1 point for each incident) 11. Is the individual detained solely for civil immigration purposes? 12. History of prior sexual victimization while incarcerated Total: Score of 4 or more on items 1-12 = "at risk of victimiza!ion" AT RISK OF ABUSIVENESS 13. Sex offender with adult/child victims 14. History of domestic violence as a perpetrator 15. Prior crimes of violence (excluding sex offenses, domestic violence) 16. Incident reports for violent offenses while incarcerated (excluding sexual misconduct) 17. Incident reports for sexual misconduct while incarcerated 18. History of prior sexual abuse perpetration while incarcerated Total: Score of 3 or more on items 13-18 = "at risk of abusiveness" Does the detainee require referral to mental health? 0 Yes O No If yes, provide the date of referral: ______ (Referral must take place within 48 hours ond the Shift Supervisor must be notified prior to housing) 2020-ICLl-00006 328 Attachment B (9/2016) ') I ✓ ICE CUSTODY CLASSIFICATION WORKSHEET nitial Part 1. Basic Information Facilit : Aurora Detention Center Officer Name: b)(5);(b)(?)(C) Last Name: □Reclassification First Name: □Special Classification K.. c:t-� l tus at Entry Stirus Whea Found Lcng1h ofTime llleg,lly in U.S. Criminal Record lmm.igration Record NEGATIVE See Narrative Name. Address, and N•tionality ofSpoosc {Maiden Nuoc, if Appropriate) I NUlllbcr and Nationality of Minor Cbildrea None Father's Name, NationaHty, and Addscss. if Known NATIONALITY: IMM l(b)(6);(b)(7)(C) 150 NCA NA Dale of Action 11/17/2017 MED See Narrative Passenger Boatded at 04/ 19/1976, NYC, Fl - Student Cmplxa Occupatioo Scats and Morles 9001 Poze Blvd. Thornton, COLORADO, 80229 None Tehran, IRAN Weight 68 Date, Place. Time, and Manner of Last Entry DmofBirtb BRO BLK Height U.S. Address Eyes Hair Sex M Monies DudPropcrty in U.S. Not in Immediate Possession None Claimed Name and Address of(Lut)(Cumut) U.S. Employer Fingcrprirucd? Ill Yes D No T)'!)C of Employment Systems Checks See Narrative Sal!"}'_. Charge Code Words(s) See N arrative . Employed from/to 500 Weekly See Narrative See Narrative )t{r Nurative (Outline particulars undc-r which alien was located/apprehended. tnclude details not shown above regarding time. place and manner of la.st entry. attempted cotry, or any other entry, and clcmeots which cstabUsb admin.isrrativc and/or criminal violation. Indicate means and route of travel lo in terior.) Right Index fingerprint FIN: 1238805650 Left Index fingerprint ·.:: ·.. �-: :· -�!�:; .: ··: SCARS MARKS AND .. CRIPPLED FINGER(S), RIGHT HAND - Index finger Subject Health Status The subject claims good health. Subject takes methadone for back pain Current Criminal Charges ... (CONTINUED ON I-831) Alien bas been advised of communicalioo privileges Distribution: FILE DETENTION OFFICER b)(6);(b)(7)(C) (Datc/lni1ials) Received. Officer: on: J(b)(7)(E) November 17, 2017 ExaJDinioe OfCiecr: Form 1-213 (Rev. 08/01/07) 2020-ICLl-00006 331 "-"vaaL&H uuLavu &. c:ae,c lUI ) ·1.Alien's Name I SAMIMI, KAMYAR .a• VJ Ul File Number ) ate 022 732 918 ---;' 11/17/2017 � .,-,,;:-.,.,,,... Event No: �b)(7)(E) I 11/17/2017 - 8 USC 1227 - DEPORTABLE ALIEN Current Administrative Charges 11/17/2017 - 237a2Bi - DRUG CONVICTION ------------------------------------- Previous Criminal History On 02/08/2004, the subject was arrested for the crime of "Cocaine - Possession" which resulted in a conviction on 03/06/2009. The subject was sentenced to O year(s), 0 month(s), 0 day(s). Records Checked (b)(7)(E) NAME AND ADDRESS OF US EMPLOYER Impex Auto 6490 Federal Blvd Denver, CO 80221 US TYPE OF EMPLOYMENT Operators, Fabricators, and Laborers ARRESTING AGENTS b)(6);(b)(7)(C) FUNDS IN POSSESSION United States Dollar 22.00 At/Near Thornton, CO Record of Deportable/Excludable Alien: ENFORCEMENT PRIORITIES SUMMARY: -SAMIMI CLAIMS LAST ENTRY WAS AS AN Fl STUDENT ON OR ABOUT 04/19/1976. -SAMIMI HAS NEVER BEEN REMOVED. Signature b)(6);(b)(7)(C) Title DO 2 4 ___ of___ Pages Form 1-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 332 ... • . J ) - .U.S. Department of Homeland Security I-213 � Form ________ tion page 1or . Continua File Nwnber Date 022 732 9�• ...._ o _____....., 11/17/2017 Event No: lb!>U ' ,--1.�FAl',ll_,,....-��-N.iiN,.......,,E=-: -::---,,...-,-,--l ,-,.el e)--,s----,Rrst,,....-Narre (C'.ajjal SAMIMI, KAMYAR _ ) (b)(6);(b)(7)(C);( l:;UDJece J.U: h\/7\IC\ Middle Narre 4.Alias Evene No: b)(?)(E) 2/,ge ? 64 IRAN 1ntryot0tizenship S.Date�ed November 17, 2017 7. arth Date 01/03/1953 9.Sex 00 Male 11. Rte Number □ Female 022 732 918 13.0NS 8. Birth Pfare IRAN □ 10. cs::./WA ':sveJJ 00 Yes No 12 Ben:! Ir (Explain) DatePami Yes 14 Med'tcal Net 0 Yes 00 No 15. TRANSFER DATE 6.0'lice DEN/DEN �llts I-or (Bepodaci6a O cmlqm paml de ICPJER.O. paml � 0 Sapmvilala. Loi miembrol deJ atilldo ffllJDelNll• uJdl la iahmacdJll npodldl confidcod•1 y aolarneare wu1e1• ,con k>I fimciomrios epropjedos que neoesila lllber. Si DO csds c6modo repmllado el who a1 pa101111, tiaa ocru opc::ioaa· • Uaman bmaJario de IDlicitud (pedido): o 1Smcnlll me queja a:zila de emagc.a,ci. para dc::«a,Wlos. Piede obcma­ el fonnuJerio de Ill vivienda al O&ial de unided o un Supervilor deplama. • Imme de) problcma al ICE OPR nc: 1. Ummr: 1-877-21NTAKE 2. Fa: 20,2..344-3390 3. Com,o cloctrcSnico: IoigtJJJ11kG@dbftgovo 4. Blcribe: 14475 P.O. Box 1200 Pamylwnia Aw NW w-,.�. D.C. 20044 • Pm coasac:m a la 010 de la DRS de &tados Unidos: I. I.Jamer: 1-800-323-8603 o 1-844-88M357 TrY 2.Fu:202-�o 3. BIClibe: Oficim dc1 DBS dd lmpeclor Gaaen1 A1cacida: Oficina de la Jfnea de 1u inVCltipcioaea 245 Muaay Drive, SWB Edificio 410Mail $top 2600 Wubingtoa. DC 20528 1 • Umd llmbiaa pucde pemr a un &miilier o iinijo en coriticlri con ICE o -010 piiia Ulfed • lnbmc & Ill ftmcioaerio comuJer "Presione "9" mun �bao del detaiido en su unided de vivieada; 11emada• •1n6uina11 adraD # 000000 camo eJ a6maodepin I.Jame sin coeto a laoficina del lmpcc1or Ge:acral (010). Loi u6metw de telffi>Do IOll: • De ICE informes de deCenci6n y la lfnea de iDfonmci6n l-8SS.351...o24o9116# cleldc el tclffooo del di-cmido en 1ae urridadee '1e vivienda DBS deJ llllpOCbJr General 1-800-323-8603 0 518# dClde el teJffimo de] ddcaido al .. 1midadN de vivienda Pndr:r¥e wcr:e rmrmnr· Jndividuol cp 1'epo,1P ioc:idJelptee de ebuao O 8COIO ICXll&les II) coopenn COD Jae ilrva;tigacione, IC proqe.'6 IOQldra repaaliee par ocraa pncm. Eau rnectide• ,te protecddn incluym tr...w&acnaa, o cambioe de vivienda .,.. vfctiw ., _..._,._ elimilieeic5n de�•� o abmadorea de comacto coa Jes vfctimu y Joe leMcic,s de--. -r-1v emocionaJ. c- fi( ·., . -·;·•••1•<1'6':Wli, �-�-.Wtl½ �4'7't .... . -1 ... �-.-. ---.,;.z.-.;;: '!lt.- . . ., . .- 8re:,Cf9•Ipn1:k..,,_4eAbuoIHH,IOfflPlli OModo la imtituci6a 1e hlce eonsciente de 1111 abulo/ualto sexual o dmuncia de acoso, se tomar6 acci6P iomediata para protcgcr. le presmda vfctima y rectoir 11D e:wnen m6dico. ----- �=r:.::z:=:.�/ �-;;z; � 7ID#=o,, \' - \ \\½\\� fecha �deeeniciJ He recibido copia del folleto de la Notificaci6n de ICB Abuso y Asalto Sexual �7.:� ICE Form Only 2020-ICLl-00006 341 Attach ICE deewi� label here ..,_IMJ, PcbtwrBMQhI Ber e-e,deAcOfftfflkePee I unda.uod Cbe GEO Aaron Detmtioo Facility ia wmmilkid ID afety, ml IDIDDDW • :r.ero tolenmce policy reprc1mg 1e1U1J abusemd aemal You bavctbc ript 1o be he &om lmlll ablllC, uaalt and baramnent. Bceerflr InddenS! •c 5wHnz •!5me1MPRetrBe• t; lfyouan:a victim of aaual lbule/waJt or sc:mal Junumeator baw urpic:ioDI of1CDaJ abu&'amult or llelllll hlnwment you tllould report it iu11wdillely to IIIX mff' llll!INll!'Z, 1o includr lwmlina-.mit officcn. dcporlatiw ufficm or any Ja.lBR.O� medical llaft'or aupavilcn. sad'membm bep 1bc rq,oml infmmatio.. c:oofidmtill and only dlaca• widl tbe appr+iade ofliciall Oil I need to bow 1-ia. Ifyou an: not coadbrfabk "8tiaa 1bc amaJt to� )'Oil haw odler-opeiom: • • • • • • • Fill out. requmt bm (kite); or file. wriUcn Ol aneapoc, dcmnee pieYanc::e. yOU CID - tbc bm 6om )VUr' homing unit officer ora &cility IUpCIIvilor. Report the pvbJem ID ICE OPRBC: I. Call: l-877-2JNTAKE 2. Fu: 202-344-33� 3. Email: Igipt!Jdlb@Pte IQY or 4. Write: P.O. Box 14475 1200 Pmmylvaoia Ave. NW WMi111na, D.C. 20044 To c:oab1ct 1bc U.S. DRS OIG: 1. Call: 1-800-323-8603 orTIY 1�357 2. Fax: 202-254-4297 or 3. Write: DBS Office ofllllpec�o. Genen1 Aamtion: Office oflnvcsaiptiom Hotline �SMumyl>rive,SWB Building 410/Mail Slop 2600 Wubington, DC 20528 You may also ale a relative or mend to cmdlct ICE or OIG for )'Oil Report to )'Olli' CODIUlar officill Prea TOD a deflince telephone in your housing amt; IDODYDJOUI calla enta' 000()00# U tbc pin Dm1Jber Call at no expemc to )'OU lbe Office oflnlipecb Gcocnl (OIG). The phone numben aze: ICB's Defadioo Rq,orting and lntbmlllion Linc 1-888-351-4024 or 9116# 6om 1be detainee telepbonc in the bousioa units DBS ofthe lmpector OcmnJ l..S00.323-8603 or 518# fiom the detainee telephone in the housina unm rr,tecdpp O:t• BdlledtP; . iavcltiptions, lbaU be Individuals who report aaual abuae or harulmeat incidents or ___ cooperate with � &om relaliltion by lnDlfa1 fur victims or lbusen, removal ofalJeecd 11d" OCher individuall. Such pu,cecuoo meuura include homm, cblnpl nr or abusers &om CODIIICt wiCb victims. IDd emotional support servic:a. Sexual abllN and/or UIIDlt ia never- an accepcabJe consequcnce of dcCmtioa �PPdinrSPIpddgpo{Sppal Abate,,. U,qppp9r. , .When tbc &cility bccomca aware ofa ICXUII abule/.,..ult or harusmcnt complaint. irnmectiafe acti on will be 1lbn to protect the alleged victim to include receiving a rnedic:aJ n•rninadon. ·• • I have received a copy ofthe ICE SCllual Aba,e and Assault � Detainee Signature/ID# ICE Form Only Date p : � ��- 2020-ICLl-00006 342 Page 2 of 2 [Telmate] Aurora CO Ice Processing Center: Inmate Edit Call Time Duration Booking# Group T V !Any !A�y Area Station Destination (b)(6);(b 720-93 720-93 11/20/2017 16:49 01:00 22732918 Medical MedIsolation 11/19/2017 18: 13 05:00 22732918 Medical MedIsolat,on )(7)(C) 1 �eason. �_(3ny v I Audio 1 Alarm, I iD no answer >j I 0 Flag All 0 Telmate US Server. Copyright© 2017 Telmate, LLC. All rights reserved. 2020-ICLl�OOOG 343 12/5/2017 [Telmate] Aurora CO Ice Processing Center: Inmate Edit Pagel of 2 Detainees Details » Kamyar Samimi '' Kamyar Samimi Detainee • Released DOB (Age): 1953-01-03 Booking #: 22732918 Detainee PIN: 776032 Room: Medical Detainee Balance: $0.00 Calls & Deposits Messages & Photos Call History Detainee Deta1\sContact InfoGroup/stationsDest. NumbersAlarmsCall RecordsS ummaryV01ce Verification AttemptsV01cemailPrepa1dDepositsFree CallsAuditNotesCaseslnvestigation Tools History Detainee / Destination Destination # ______--" ._L Time Range Station Starting 111,15,201100:01 1 liiml Group !Any vj frrml Station �gro up vJ mm dd,fy,,, IH1nm Search Run Report> Saved Searches > Reset Search> • Caller V < Call CO +Add Burn all calls 2020-ICLl-00006 3t4 12/5/2017 The GEO GROUP, INC. AURORA I.C.E. PROCESSING CENTER SUPERVISOR SUPPLEMENTAL REPORT CASE. UMBL:R .____I J ____ ,--------,-------�--,------r-------,-----:---------, ervisor's Nam rint) Time Date Out Assionmcnt ;(b)(7}(C) Supervisor's Action(s) and Summary· On the above date 2nd ime b)(6);(b)(7)(C) alled me to medical. When I arrived t)(B);(b)(?)(C) _rwas stan mg with the door open at · · cell door 527. Cell 527 was t e cell where :732918 was being housed for a · . • When got to the door wa� I level one suicide watch, and b)(B);(b)(?)(C) g on a ma ress on his right side. I lookt'd at looked down on the floor an the detainee and his e s was open and he looked pale. l asked what was going on where" as the nurse. b)(5);(b)(l)(C) stated be went to call the doctor. I thought he looked rctty bad and need to go the emergency room. I went into the nurse's station and asked b)(6);(b)(7)(C) if he nm: callinl! for an ambulance and he said that he was calling b)(B);(b)(?)(C) for permission and that he called (b)(7)(C) b)(6) ; him twice and had no answer so now be was callin • I stated that we needed an ambulance now. At that time he was talking to (b)(B); (b)(?)(C) o I went to the phone in front to call 91 I and get an amhulaucc nurse's station and at 1110 hours I told Control b)(6);(b)(7)(C) sent here to the facility emergency. I then went back to cell 527 where detainee Samimi was lying on the floor. He was breathing and moving around he was covered in barf and saliva and I could also see blood. I told him to try to lay still that an ambulance was coming. He acknowledge me h." looking at me. I then told the Officer to stand by for the paramedics and that I was goin� to the the transport officer that will go with the ambulance as escort. armory to hand out wea o C) b)(6);(b)(7)(C) and b)(B);(b)(l)( After issuing them there weapons, I returned to medical" herl' w en I arrived there were abo gbters and paramedics working on detainee Samimi giving (b)(B);(b)(?)(C) and asked what happen. He told me that he was breathing him CPR. I looked at when the paramedics arrived then all ofa soddeo e stop breathing. I then went to the phones :rnd j called fb)(B),(b)(?)(C) _ I then escorted the paramedics out to the ambulance. The ambulance departed to University Hospital Emergency Room at 1136 hours. All required personal notified. EOR 1110 l 2/02/20 I 7 Watch Commander Recommendation(s): Forced Used: 0 YES @NO Explain: 0 YES @NO Type: Restraints Used: Time Applied Justification: ) ---------� C-:(b"""' )(7,..,.)("" .,,.b.,.,, )(6""");-::• J Signature: Date: _ 2020-ICLl-00006 345 12-02-1?- General Incident Report The ,·GEO Group, Inc. -Auro.ra/LC.E. Processing Center Subject:· Frease dr«kono ofthe app,op,iatt> boB$ El 0 0 □. �,tty Breach Major At9 Med. Emetp«1Cy Contnabaod To: (b)(6);(b)(7 .From: b)(6);Cbl(7)(Cl )(C) Detainee: Title: L1 __ Tltle: ..D/o '°' S'� i Mt -, �]'JdZJ?.z.73,2.qig Pf1fH Name .,......____,__ O Rules Vlofatfon 0 � Od.aln#on O«alnee Assault D 0etalnet1 on staffAssault 0 DetalnH ln/UI')' D M/norlh □ SelfHam, □ __,),(alorDlstutbance 'O Maintenance 0 lllnorDlnur6ance D Hmw«-Stdb 19"' oth«: 5'vt I CA f)/3 t1Jk[Ct1: Date: Pi;c. o:i.,, 2-01 7 Time: //.' oo Location: . ,S /111 CA P1§ /;r/-'r1?:,f/ _£2-,7 sws.27 Detainee: Donn IOI PrtntHMne IDf . : iirint Hime · Details of: riclde.nt : .. (Pleue-Ptfnt• H11M1 How& . YouAwstSta . );(b){?)(C) � ){6);(b)(7)(C) b)(6);{b){7)(C) so offoroe Report•sub(lii b)(6);{b)(7){C) 2020-ICLl-00006 346 Donn General Incident Report □continuation r�·]supptement, The GEO G1·oup, Inc. -Auroru/J.C.E. Processing Ccnkr f Subject: fl/li/Jtco---f' W,1--fcti I Date: Time: / IOO Details of Incident {Continued) (Ploase Print· �. "'1Ja� Mien, Where, How &Mly. You Must State Facts And AbsollJtely No Edlf�llzlng) . . ... .. -·· ..·· . ..:.··· --.•:· . Supervisor's-Assessment (Continued) . (Please Prtnt and Include: Date/Time, If AOD 1111S � wt,6f1 and by Kflcm) . ·£.� 5v:J2-½ U, S Cf\. W u-l--clA . (b)(6);(b)(7)(C) (b)(6);(b)(7)(C) J General Incident Report The GEO Group, Inc. -Aurora/LC.E. Processing Center _ Subject:· 1-H ch«:kone oftheapptopdate boxes El. �rftf Breach Major Are Med. Emergency Contrabar>d D D Rules Vloiatfon Mlnorlh D Maintenance D Hun[/«'Stdlce 11tfe: l...-,----�--,---- Titfe: bl<5 >; To: .From: (b)(6);(b)(7)(C) Detainee·• ·· · - Ka.wr 50.1v,,ro, Pf1rit Name I . : . -P.rfnt Harne ,. � .,.,,. Dlffllft,anoe 0th«: □ □ ,, ):> ( 0 Dtltalm» on StaffAssault � fn/Ut}' Minor D/sturtJan«t Cro$¥Ln+ W9,:k+:-:: Date: t� I 2-I Location: M�- IS� L, 11me: l Io O It). s�, Detainee·• Pr1ntffame IOI . YwMust6tateFa«sAnd.Ab$olut'1YNoEdllot"!fz,kv) . � \ct {: �v ,CJ.ct,e.: .b 7 , + \ \Q� .• l'f'\ °"""� �l't. •he:i_\'½4 p.,r;vUI 11..y· 'j MIY'\)W� .':"-'°�' 5'\.�11-Y"\1 wB:�·bree,,�,'f\ -�\-"�r· "- f,.(...v VY'\•() . ��.e.- . +k:Y:) \:X-e;io.·n c.pR. M::\c+,N.e.. Lug,S,. � o...\f Ii1>v . , G..Q\!ff2�\ffi� � i;, · r,e.. , 5�·,c.1 Donn IDf (b)(6);(b)(7)(C ) ()1\CA.. tMT -�l'Y"\� . €'.M+ D IDf· =-.:...;.;...;.;..;.._;..;;__;.;..:.;�1,..-..-..!::::I!�=.,..;.;;� , : a.�n�. bi s«fHMm Dohn · Qetalfs· of·fncldent . m.«a, mien,, How& c . C nocl..3 □ □ .'27:,3,2C\IC/ $':)., IOf ,,.�. 0 \. Oda/nee on �•lnee Assault - b)(6);(b)(7)(C) L--------.-------..,,.-,,?.'2.IT-i:. 1;�n �or:r�� Prlifl�Ntinietmd.iiJe. &teAndTim�· 2020-ICLl-00006 348 Cill , � c...,\\tJ General Incident Report The GEO Group, Inc. -Aurora/1.C.E. Processing Center Subject: □ □ To: From Please check one of the appropriate boxes Security Breach Major Fire Mtld. Ernerg«JCy Contraband b)(6);(b)(7)(C) D D D D Ruin Vlolatlon MlnorRre Malntanance D Hun,.,- Strtke Title: Title: □ D □ a.ta/nee on Dttta/ru,e A•nult S.lfHarm Ila/Or D/$tUrtJance Other. J.,-f- C/2- IOI D D«•fn• on Staff A•sault Detainee Injury Minor Dl1turtumce 7 Date: )Z Time: � Location: - . Detainee: PrtntName □ □ Donn 1/c:,b Print Name JD# Dorm Prtnt Name IDf Donn Details of Incident Supervisor's Assessment (Please Print and Include: Dat&IT7me, ff AOD was notified, when and by whom) ,,.1.. � �11� V-i �(I\.. .C-Y:6'al t � Use offorce Report sub 1$/ll . b)(6);(b)(7)(C) ame and 1ilft. Daie And Time 2020-ICLl-00006 349 General Incident Report The GEO Group, Inc. -Aurora/LC.E. Processing Center _ Subject:· Fw.se dltJd(oae d the llpp(Op,iate boxe$ El. □ □. . To: D Rules Vlolatfon D Mlnorlh �rftyBreach Major fire □ Med. Emf!f'IJ«'CY Maintenance D Contraband HungerStdlce Title: b )(6);(b )(7)(C) .Fro1 .. Date: // •07. · r? Location: {),o -Z... "2...i'? -h?� (jO Detainee: � 'f 18- 10, Donn P�Name IOI Donn P.rlnt Harne IDf � P�-.� IOI Donn· - . ' Ot-:0� b)(6);(b )(7)(C) � Q�:-r- �-vi .. r It.A��, .... I o\,l� ......c f.:bof2... (l'T'\ _, 0 � J :z::: � ht4C Ot:j� . \ J �,-t::6 l t 'I,,' l.l i2.JLt� ,',.._ � hr>,_., 77'\ ...,.,o,e.,,:::t;; t=,- - I - OE-�.\•- ,...... ,';././,,.,--,. d ·-�1 I +1--. // /"'J,�l...t...A �J._,_. ,.J J/..uc,,,. .. . j: .. .. ' .. ·, .. , .. •' � ' ,:; (I.. lib )(6);(b )(7)(C) 11tn.i - .,.. - - -� . . .' ' ,, h'r L.� ;.., ' - t, r,' ,: rR"c. .J"'\c_.. �'tl....N"\,.\\&.. - t12f Time: s-37. . {Pfease-Prfnt• '1flo. KTlaf. � m»en,, How&fflO". YouMustSlate.FactsAndAb«Jfut.wNo -b)(6);(b)(7)(C ) -A-&✓ro- L,.A Ea.,£... � � -r,.....,e;. 0 .�,, DetuiH fn/ury MlnorDfstu,t,ance Pt'1nl Name · Details of-fricldent 'i'fi� Detainee on StaffAssault ' l-r- lltle: Detainee: �i• k"""Y� /�- 0 I....Ddafnee on D«alnoe Assault D D ii«tHMm D D Ma/«' Dlstutt,anoe □ D 0th«: ·· : ··: • ·· ··-.· · · �f',lntll!d�Dat�e.·1�.was""!'6«',wh«t�;; . .S4 . >�V'f�� -- §'-'V'd t Y-1. $\Jpetvlri(s·Aeses�menf ... � �- -· ............. --· -·-. .. . -· . .... � ·· :- ..... ' .' (,CA.. • .• i l :. ,. ·' .. b)(6);(b)(7)(C) �Rq,oruut .. - ,· (b)(6);(b)(7)(C) " ..,. . 2020-ICLl-00006 350 12/i/t� -•·r--:-••-•••--·•-"' LHJ(eANJTime /r,u p aes General Incident Report Aurora Detention Center The GEO� Inc. Su.bject: Plee# check ooe ort11e llPPfOllliat• bates □ �rtty Bl'NCII 0-., Fire Oo.ta1nee Injury [)M.,nt.n.nce []Minor DiaturbanCe [JM.Jor Disturbance TitJe: (b)(6);(b)(7)(C) Slrlll• Os.1tt1ann []contraband -�nor Firt To: □�•' Rules Violation □ , Detainee on Detainee Asuuff .,..,... on SllfJ Assault (21-"1ca• Emergency Olher. _____________ wd·ch cawspwk;oate: 11-- o-i.-i, Tttle:,!nkM,h�rl.ocation:.,L. r,=ed=•=-= 'Q:l�' ________ DetalnN:$a.;, "'� ,\So!AYOV: T ' Detainee: Detainee: Name ID Details of Incident · Please Print - who z;z. 1 3Z/=tr\ 116 Detainee: m , Donn when wtiere how. & wh ----------,-D---Donn -Name (' NarM Dorm' ID Dorm .. • You must llete fecu Supervisor's Assessment Plnse Prinl end lpclude: Date/Tme, �r AOD �d. f"hen, and by whom. :>� S\..,..('1:1'.":VJr I'\.. (b)(6);(b)(7)(C) .f> f< JN-,..-1,- . Use of Force Report sub b)(6);(b)(7)( 41<. ��nocum,.�et:-;s�=:a-=s:--z,,;:;ig:==:..:tute=,-,,,;:;===-::-��..d"�-:-+-�..:;.;;.;,.... r------.:minr.::r1!11"1S�Bffl77l"'Tl'l'll1'11"1'1""""'.....,// 118 2020-ICLl-00006 351 General Incident Report The GEO Group, Inc. -Aurora/1.C.E. Processing Center Subject: Please check one of the appropriate boxes □ Security Breach □ Major Fire W □ Contraband Med. Emergency D D D D □ □ □ Rules Violation Minor Fire Maintenance D Hunger Strike (b)(6);(b)(7)(C) Detainee on Detainee Assault Self Harm Ma/or Disturbance Other: D p D Detainee on Staff Assault Detainee Injury Minor Disturbance Fro Date: / Time: �"-"--"'--L--,:_____ Location: Detainee: Detainee: To: Print Name ID# Dorm Supervisor's Assessment (Please Print and Include: Dateffime, If AOD was notffied, whej and by whom) SAL � l:':)' .,..._vf(n .f :vf p � 2020-ICLl-00006 352 ! I Do Print Name ID# Dorm Print Name ID# Dorm General Incident Report The GEO Group, Inc. - Aurora/1.C.E. Processing Center Subject: □ □ □ □ Please check one of the appropriate boxes Security Breach Ma/or Fire Med. Emergency Contraband □ □ □ □ □ □ □ □ Rules Vlolatlon Minor Fire Maintenance Hunger Strike Detainee on Detainee Assault Self Harm Major Disturbance other: □ □ □ Detainee on Staff Assault Detainee Injury Minor Disturbance Time: 11 � Title: L,a,,av,.,.,, Date: l�-;;,-\7 To: f'(6J;(bl(7J(C) Fro1 J---- Tltle:�N§PoQ;t: Location: -� __-A_vQD�W:�-------_ L___ __ '::>4N I N 1 1 � 'l � d,:l, 3:)qtft,Detalnee: Detainee: Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Print Name ID# Dorm Details of Incident (Please Print - Who, What, 1-'Vhen, 1-'Vhere, How &Why. You Must State Facts And Absolutely No Editorializing) 5 }U.AN'?io•g:cl(b)( );(b)(7)(C) I 4N0 1') N"-iS:C.Lf wii¼ AO\Jt 56.f) 0 � �� :¼o Al>,M ve .Do "1S? A i'¼QllAl, tEIY\f&bf:;N(\J. 'I. '-AN6 Ar0\)1\J.Q 8AUL TQ e.,\ c& �MQ.v �CGr \t,,, L::r\,! t)G-t:Pr INS6 ,NS:,c.G ME,O, w L £iec .C'E£T 1 1',J } ANO TbA-h\ Supervisor's Assessment rv--r� (Please Print and Include: Datemme, if AOD was notified, when and by wflom) >--u- .Sv..�v,� svvi11 tt...�· (b)(6);(b)(7)(C) Use of force Report sub --.12.AN":>Po e._ I • (b)(6);(b)(7)(C) 2020-ICLl-00006 353 (b)(6);(b)(7)(C) TRANSPORT/ESCORT LOG (b)(6);(b)(7)(C) J b)(6);(b)(7)(C) J Escorting Officer (s ).j_____ J-----(Print Name) (Print Name) t..... J----------- ____ '1'-'0 _3�0'-------=-______ Time of Return_____,\'-- S Time of Departure ----'-1 _._/ .... Vehicle Used: Model L12Jo LJ 9 i3_3'-,3J.-_"o_"-----"' S o'---_ Starting Mileage:__ (b)(6);(b )(7)(C) Make �oW VIHV Ending Mileage: �b)( 6);(b)(7)(C ) Supervisor Signatur,.__________�__ Date: 2;>,]C> S: 2} Ja-a.- 17 Transport Officer Signature: ____ __ ____ Date: ______ ___ ORIGINAL: Transportation Lieutenant CC: Business Office :HSA 2020-ICLl-00006 354 General Incident Report Aurora/1.C.E. Processing Center The GEO Group, Int SU bject: Please check one of the appropriate boxes 0 Security Breach 0 Major Fire 0 Minor Fire D Major Disturbance To: l (b )(6);(b) (7)(C ) From: (b ( ( )( (C l ) 6); b 7) ) I I 0 Rules Violation D Contraband D Maintenance D Minor Disturbance 0 Hunger Strike 0 Self Harm D Detainee Injury Title: t .7, Date: /2--2--/7 Title: Location: /J/e. Detainee: 0 Detainee on Detainee Assault Detainee on Staff Assault �Medical Emergency Other: Time: I 1,.()D Ct,;i,,7/2,()� Detainee: Name ID Dorm Name ID Dorm Detainee: Name ID Dorm Name ID Dorm Detainee: Details of Incident Please Print- who, what, when, where, how, & why. You must state facts (absolutely no editorializi � b)(6 ) ? Y (b )( )(C ) r.Y//5 ::r�PP/.n&.tJ (J'I �o �u;' OW 12:--Z.-/7 A--r LJJo -5lfl FoA ,f nRIJ;'C.,f/.. £HR�C.�,,.,,,t,'l... I. C:./JLl-:_ft_l) 9..11 ,4-A--/) /l/)il,f6P 71iB. f2.J/!__/J7(.;f.J� HntAs .. :r l+T tll'JIPtl�'i 4-11/tQ/I./JI.,r1tl -rM-R- P.#-t,t,,"1'1 IS'/ rt-1-A-1 ','/Ji /v'llR�nl)A tA.1-1BuLB/l-'"c,,11. 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R_ec_o_r� d���=� Medical Unit HX:...\lil!ll·' :' ..... .. -----------.' .'• Name of Delainee:::')0..lY'{'rY"\ I Violation or Reason: NJ A- Admittance Authorized by: I Pertinent Information: .. I bo..ro1¥1 V A#: 227:) ") 9 lsr NJrik/ tJ()r-S e... L Disciplinary Segregation □ Medical Observation 1st \\\21..\ \ f'\ 1-n2 _d ____, 3rd / I- 25- n;2b li:i\\\� \x 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd l'j &ff. /U' \' 1-z.�) ]I 11/Jo/n - Date Released: ____ Time Released:_, ____ Administrative Segregation Protective Custody/Special Management □ Room#: p)(B);(b)(?)(C) Date Received: \.,1 l l1 \ (7 Time Received: 23 l9 roe.d\.CA,,I DD:):t;r vo._..\-, Ol'i □ . 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd Pertinent Information - Epileptic, Diabetic, Suicidal, Assaultive, etc. B (Breakfast) L (Lunch) D (Dinner) Shower--lnd1cate Yes (Y); No (N); Refused (R ) Rec (Recreation) -- log in actual time, i.e., 0900/1000 Medical staff will sign the segregation log and the housing unit record each time a detainee is seen. At a minimum, the unit record must be signed at last once each day by a qualified medical staff member. Comments: i.e., Conduct, Attitide, etc. Additional comments on reverse side must include date, siganture, and title. Housing Unit Officer Signature: Assigned officer must sign all record sheets each shift. 2020-ICLl-00006 371 1i.2lf.\l 1)'\c\-- vvt1.+{;V\- COMplafnivt9 M ls VCVlj 5:f(/4'.:, i1) hA � m M�. !2--{-hA�d 1t m.+ c:J,j nvt.Q;r �hd a,st-ed. +hod- I Vt'YvtbV£ 1+, 0i,ih� vv I IA,\S \ v1. h � , ---fvD WL vi.is- Vb b M 1AS .-t-1,,Q � ll w OS \-Jt,+\M%1t)g hIM �v etJ--ti> 9t-hi � i-v n>GM-ft>r 40 MiV\t: L,{H dw. -tb lApfC-t- �Vl,1� OJ\J- � � io l,\,� ---t1,,u r-eJ-fvvDf'\J\. ,t-¼ve olo� vvec1 l,Jvu tett a_ -Pf w p1cus MJI� o-f- ovitvi� 0J1d-- Jrin� Betel:- i6 TV roCM elf ZI/D - 2020-ICLl-00006 372 _!;____ ___ M_e_d_tc_a_,_u_n_i.t( Name of D etainee: _£._l--C..l�r:u..,.-----P..���- A#: Z21:32.. q IY Violation or Reason: _____________ __ Admittance Authorized by: -,..J'--'-'--'--i:'--""---1--+:.....;.....=.a....,."'--­ -��-,i. �.··-�-g_R_e_c_o_r · _d���!!!!!!!!!!!!ll!!!�-- J/tyh't Room#: JbJ(aJ;(b)(7)(C) 2/ O 0 ---- Time Released: ----- _Dale Received: I Time Received: Pertinent Information: __..1.-Ji..;.,c::......�=�..::;..--4c,,1....,�--<...1r:;:::...;=--;::___;�--------------­ Administrative Segregation Protective Custody/Special Management D � • •:•• ""O • • • •. • • .. ••• • • □ I " • • •· Disciplinary Segregation •• □ Medfcal Obs�ation � b•::·-_,-__ :$ 1st )J- \-l 1 t--_d -� 2n 3rd 1st 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd Pertinent information - Epileptic, Diabetic, Suicidal, Assaultive, etc. B (Breakfast) L (Lunch) D (Dinner) Shower--lndicale Yes (Y); No (N); Refused (R) Rec (Recreation) -- log in actual time, i.e., 0900/1000 Medical staff will sign the segregation log and the housing unit record each time a detainee is seen. At a minimum, the unit record must be signed at last once each day by a qualified medical staff member. Comments: i.e., Conduct, Attitide, etc. Additional comments on reverse side must include date. siganture, and title. Housing Unit Officer Signature: Assigned officer must sign all record sheets each shift. 2020-ICLl-00006 373 L I .) SUICIDE ( WATCH _ J" AND NOTES bunate/DetainedResident (I/DIR) Name: n.., : IV'"l M'" . Inmate/Detainee/Resident (J/D/R) Number: "a 'J I 3 ;). 1 I S�- .' Shift: ) 5-f·Location: ¼,ire.... I 5'.: Check appropriate JeveJ of observation: 13. Lc:ve1 l LeveJ2 G,l Fifteen Minute Checks Constant Observation Restraint T)'Pe: ---- ---�----------�-­ Items allowed (dledc approprj•te box): 18:J □ '3 CJ Suicidal Blanket SQioid1J Pillow Coc1e l!:KoJ1naH011 l. Bc,lin• on door/wall 2. Yelline ot �M 3.CM:IU!. ... r..-:.._ 5, UwthillR .6. Sllblim 7. M · ... mcohem>tJy 8..- p. ., Time 0� 0::/:_'5"0 0.-/55. Cfi'Ol) (}�015 ' /')g'J 0 (AZ'/.!5· l')�./2-0- -·.·· -mu 08'!2-!5. n..i:r-:30 I 0, LVDII• or lilting u. /'Y?3Y-- Ouiel. J2. Slemhut 13. MOIis �eailell i �"'6 ·en 14. Fluidt 15. Bath/Shower 16. Toilet 17. S (')�4-0' c:s+s- oE'so .. I 10 C95V c�T"'.'..::. JO ID IOCV /M�- /0 Jnlo JO JOJs 10 ,o LO� JoPs. /Q ;D '.lo� JO /0 /()././0 /O¢r /0 JI .J.Z /0 /0 /0 .2. 2-0 2-P..o Vr.60 �U) I/� JO 10 (//00 /{} /0 oqz.c:; JO JO Jo /0 /o3r· �.20 JO 0010 ,o I ::.---T-' ID JO c;q,s- Undergarments n.1.-.· Vlfl�• \'"1111 Tfme ·c.uclu Matte oa J/1>/lt lime Initials Code JnJti■J1 Code (b)(6);(b)(7)(C) 09.30 10. (b)(6);(b )(7)(C) /0 o�� ,0 09-40 10 iO 68.5."5" 09tO. 090.> 1 a. .Reabaiau LciQICJICd J9. Ruire ofMQlion 2D. Other / Vo,,,, rn f'l6. 2J.OO>o- 8 Su1eidc Mattress BoQk /v cq:2-s Code and ■fgnature reqwred on the above dme Hn•J per level of ob11rvatfoD, -�· Staff-" b)(6);(b)(7)(C) I Jnitiala l(b)(6);{b)(7)(C) .. Staff'Si lniti•ls I have reviewed the above Jog and certify thal for the shift noted above, lhc J/D/R was observed in accordance with the req · (b)(6l;(b)(7J(C) tion. (b)(6);(b )(7)(C) Sµpervi sor Print Name Signature Rev: �212DJI, 05/2017 2020-ICLl-00006 374 Date Time ... ' • J- SVICIDEWATCH(�__,ANDNOTES .. 'lheGEOG Inmate/Detainee/Resident (I/DIR) Number: =<.� 7 3,.l � 1 I I,unate/Ddainee/Resident (I/DIR) Name: \(�� i;.y- )a...V\,Jr..,/ Check appropriate level of observation: 3 Levell GJ Constant Observation Shift: -Yr Level 2 Fifteen Minute C.l\edcs Ratraint Type: _____________________ lterns allDwed (dleck appropriate bos): fZg Suicidal Blanket C] CocJe EHIHa:tfon l. Se.■lirur on door/wall 2. Yellim ot · J.� 4. Olnim: 5, 6. 7. 8. UURhine S.ub!UIR' Mwi1blu11, incoherently -still J. W.ilantr J 0. l..wur or 1idiu Jl. Ouiet. i2. Slemfma· 13. J◄. JS., 16. 11. J 8. J9. 20. �J. ... Meals lefVlld/e,itcn en Fluids B,.ab./Showu ToiJo1 s� · · .RMll!lints Looaned RJIDRII of.Malian Olber Other Code and Undergarments � Suicide Mattress CJ S1:1icidal Pilfow- I """"'. Book c•ecu lWade a I/DIil Vh■aJ Tia,e Code I J11iti1Jr Time 04-)..? 0 'I!) '-tJ � la 04'+, 0'-f>J ""' I.I.A 0 bi,/4 �(;4.5 PPfo l'Jfd S.5 0 ?t:'OJ 0.,if '"''� 10 ..9.$'JS o..r.ss 0 6'>5' /?�)l? 1.P \ .> 0.,-.l.? O•o� 06� 5 J' lo (}�/() 9 '54(} O-:Sy5 •r?55'-, 190◄5 ro o.SJ S .J�')� IJ 6:i� (.o la 04S'i 0.Jo� O>n.5 07-Jv O�·fl: '" I -" I lO rf.1-.aP (o {) 1-.2,.S 0�.i.30 o�- lo " I fJ ( o, ti t?bl' ), ot..J.55 Time or.., P (b)(6);(b)(7)( C) IQ 0 <./'-'ti rJflo n.L-•· 0740 Code I Jnkj1Js fo to b)(6);(b)(7)(C) -�o to /a /rl Jo J� ".lo • /J I .9 lo In ,� 10 ,o /(.) /0 JO /0 /0 ••ao■ture nqu.ired on the above time II�•} per level ol observation. b )(6);(b)(7)(C) I have reviewed the above log ai,d certify that for the ,hift noted above, the 1/D/R was observed in accordance with the requ irements of Jeve] of observation. (b)(6);(b)(7)(C) Sµpervisor - (b)(6);(b)(7)(C) Print Name Rev: ()2/201/, 0512017 •' Signature ·• Date Time Suicide Watch Lo61Notu Form #HS-207.5 ... 202o�iCLI-00006 375 Inc. SUICIDE WATCH - l_ .>J AND NOTES). / see ( . ,:. . IJunale/DetaincdResidenl (I/DIR) Name: l(... "' GW" 5,,,�,•�! Shift: 7r Location: S 1 ;'1£1//c.., W..GUG . Inmate/Detainee/Resident (I/DIR) Number: �;il3:2.1ff Check appropriate level of observation: Level J LeveJ2 C.I Fifteen Minute C�eclcs l3l Constant Observ,.tion R-estraint type: ------------------�-­ Item, allowed (daeck appropriate bos): Suicid-1 Blankel Suicide Mattress Sl.licidaJ PHfow Boqk SJ CJ Undergarments 0th�:· ,:SJ □ Code Emluadon l . Se,tinl oo doorlwaJJ 2. Vallinir QI' �a.a 3, CMnir 4. n.-=- S, LauRbiu .. . 6. SUll!UI&' 7. - . . 8. ,:; iixohllreDlly ,� ,� I ;:z 0/P.$ OJ Io 11 o I I .5 OJ::}� ' 01'1 'S" � 1i!J 0135 ,0/$.,,, n 2.o.!J r.-::Jo5 &in .11l.1S- OJ�o ",\'iJ,fj .f>J.A< tJa..:J.r /Xi tJ.n w:,J.. 5'? J" o �· o� /0 ,�, ,, /0 .t> >I 5 ,,,3:;).!) oJ�S .� ,o}3.5· � }'M. 0 :J.'-tS- I -::::i 1--i 1').l. \"J \".l.. 1., OJSo {� J{) J))SS" /I() r,4()'7 .J'-105 '"' '"J-f) If/ lo lo • J � lo /n J� I .I} IP ' 0 fl) JN10 IB 01-1i.o /0 "1../15 O�;l.} .Initials I� 0310 J --:l_ I (b )(6);(b)(7)(C /() I .,.,-:,S/.7 tJJ,01) ,-:i 01 uS t?t•> v) I ::l aervatfon. es b)(6);(b)(7)(C) I have reviewed the above log 1U1d certify that for the shift noted above, the 1/0/R was observed in accordance with the requirements of level of observation. bl(6) ;(b)(7l(C ) Supervisor: • l(b)(6);(b)(7)(C) Print Name L --tL. __________,_ ReY: �21201�. 05/20/ 7 ._________l· J Signature /2- -, tJ tzt, 2-f'-r- Date Time Sulcld� Watch LoRINotes Form# HS�207.S ·• ... - 2020�1CU-00006 376 Inc. . . . j. smCJDE WATCH _ � J AND NOTES ( Inmate/Detainee/Resident {J/D�) I,unaWDetainee/Resident (I/DIR) Name: ' ' Number.: 2 2, "J 2.1'I Check appropriate level of observation: Levell CBI C Constant Observation llleGEOG Shift: -�.,,. Level 2 Fifteen Minute Checks Restnint Type: _____________________ Items allowed (dlffk ■ppropritte box): Suicidal Blanker Suicide Mattress S1Jicid1J pjJfow Book 181 CJ IZ( Undergarments CJ Ot�:· al Cl Cdde Esn11■1llo.n l. Seatint on door.lwa)I 2. Y11Uirur,;,; �ftllP 3.CMn,i . I ◄• 5. LauRhlruz 6. SlllmJU!' . .iilco.bemitly 7. � . rtiU 8. s,. Wallcin2 I 0. LYUU! or 1itliaa JJ. Ouiet ! 12. SJemjng J 3. Mal• mvi=d/eatai 14. Fluldt �e11 J.S, Bath/Shower 16, To,.1o1 J7. s . JI. D 1 JP. �ofMQlion D. Other ,-:..� -- t<.9\.(/1. d_'5 2J. Oihet V&aal TI• Cllecltl Made• I/DIil blfliala 1lme Code I Jn.ltials b)(6);(b)(7)(C) _ JO (b)(6);(b)(7)(C) L"3 ts 2/:Jn )� Jo 21�-� Jn �J2o JO I0 � 2. "'2 J 'lo .1 .::> S' I ., � :}3.o �/1./( /I)-� I Jd 2...115 ��() JV ))UT I� 2,-:1_nn JO � ')�5 �)So :>.. \ 220.$ ?0 ..(3$S JO ?"210 {() 000 111 Io :; '2/5 /f) ;2_ Oo()5 2.22.D is·� In OP/cf f () ..,')? .it t:''1/S JO :12.� 0 10 Time Code I - �,11-� ·n-�� fl..Z'-/0 ?21..v'� 2?{'0 2-?..S� ?-�00 2.'3o'5 ;t,�/'O �, 4' ,� """'�., f!(} /U t)()� /<) /::¥>�/, 10 ....,, �✓ I � )0 JO ,o It' �/;> /0 OnJ'o ' ";l 0!)<.J5 JO JO (0 / Code and •tao■ture reqlllred on the above thne 11�•1 per level of observ■don. B b)(6);(b)(7)(C) (b)(6);(b)(7)(C) J have reviewed the above Jog �d certify that for the 9hift noted above the J/D/R was observed in accordance · (b)(6);(bl(7)(Cl wjth the requirem SQpervi sor ---I re Print Name Re.,: �2/2011. 0!/2017 ·• .. Date Time Suicide il',uch LoRINoks Farm #HS�207.S 2020�1'cll-00006 377 Inc. . I £ ( SUICIDE WATCH£_," AND N.TES Inc. The GEOGt'D Shift: ·r..cation: Unit: csident (119/R) Name: Check appropriate levcJ of observation: Levell Leve12 • Constant •bservation c;i Fifteen Minute Checks Restraint Type: ______________________ Items allowed (check appropriate box): • Suicidal Blank.et • Sqacide Mattress Suicidal PiUow Book □ □ Time Coile ESDl111don J . Scatint on door/wa)I 2. YBJlim Qr icrea,niu 3, � llil.l} 5. UIJl.thiml . fi. �utein• 1. Mu:mbJ,naincoberently 1tiU s ..- ID D A\ft ,'it"" 'U& 111.r J 0. Lvin• or 1jttin2 Jl. Quiel- J2. Sltcum.11f 13. Meals aerv,d/�ten 14. Fluid1 �rvtdltaken U. B■th./Showcr 16. ToiJet 11. smokimr 11. �ts l.oQsencd 19, Rana� ofMotion 20. Otha- r.L..... ·,,.c. orrl' of u,.l.for/tl , 21. Other 4 I, -�("" �- WaUdtur /0 !if_ • '! !A) ! Vka■I Time CltecJ/Jl l. S 2. 3. 4. 5, 6. 7. Jl. J2. 13. J4. Fhu 18 Code and signature requJred on the 1bove time Hne1 per level of obterv■tion. niti b)(6);(b)(7) (C ) "tials (b)(6);(b)(7)(C) J have reviewed the above Jog and certify that for the shift noted above, the J/D/R was observed in accordance n. with the requirements _J(b)(6);(b)(7)(C) Supen1isor: b)(6);(b)(7)(C) L_______..r--- Print Name Rev: 021101,. 01/2017 __ ____. __ L.-. Signature ·• /z/t? t2(f' Date Time Suicide H'atch Lor/Notes Forn, # HS-207.5 •.· 202O-ICLl�0000G 379 SUICIDE WATCH f.J"..., AND NeTES. ti-- t- t'1' Check appropriate level of observation: LeveJ J Constant Observation □ LIT= l3I 11/ Ratraint type: Items allowed (dledc appropriate hos): tEI CSZJ Suicidal Blanket Suicidal PiJfow .EJ CJ . Level 2 Fifteen Minute Chcclcs Time otle Es laaadoll □ (!a Undergarments 0th�:· Sufoide Mattress Bo�k Visual Time C.htdu Made on JJi>IJl Code Jnlu.Ja Tune Code /0-- . (b)(6);(b)(7)(C) ) . B-:,,,-----.....,...------+�,........,._+-=;{�0 t-2::-.� �_._t-w-1 '2.- Initials b)(6);(b)(7)(C) D 3, 4. 5. 6. 17. Code and signature reqlllred on the above time lfne.1 per hvel of observation. J have reviewed the above Jog �d certify that for the shift noted above, the I/DIR was observed in accordance with the requireme:nt,s...01.��llt.flh&,:rvation. b)(6);(b)(?)(C) S�pervisor ,__ e Rey: 0.212014, OS/2017 __ __ �b)(6);(b)(7)(C) __ tz/1/!? Signature ·• Date Time Suicide il'aleh Lo,INotes Form # HS-207.S ·.· · 2020-ICLl-00006 380 SUICIDE WATCH 1 l._. .., AND NOTES Date; /I- 70- I Unit: bunate/Detainee/Rcsident (I/DIR) Name: . ------...-· .... ·--· ·- - ( . Inmate/Detainee/Resident (J/D�) Number; 227..129/T SAH1/\-11 lr/}H Y,,t,t ·Location: 5'27 Check appropriate level of observation: LeveJ l LeveJ 2 Constant Observation &I Fifteen Minute Checks □ R-estraint TfPe: ------------------�-­ Item• allowed (dleck approprJ■te box): Suicid1d Blanket -21--, Suicide Mattress· SuicidaJ Pillow c:J Book B IS)Cl C.ocJc EsnJ1uatloD ) . Seatina on door/wall 2. Y�llinR ()t scttanii02 3, Cl'\>ini! 4. Cursil12 S, La�tbini! .6. Sunrin11 7. Mumblirur foooberontly s. Staildi• stjlf Sl. Wallift" J 0. Lwi• or tiliine u. Quiet. 12. s1-11:1.1t 13. 14. U. 16. l7. JS. 19. 20. 2J. Mei.ls �eaten Ftuid1 terVedllaken B•th.lShowu ToiJet Smokina Ranmts Loosened 'bnA'I! ofMQliOD Other l'!' f fj '1 (,) /fi"'i> {'10[) I'J //; I • JC' I' L.f� V,oil> ., 0),/i -? JJ>11"') ?l!l1/4► 'L{ �-0 'lU.". Under8armonts 0th�:· Ua:J 1-liS /(rft,_ t.O-t'l �C) U) r&--rz... Uf(S JC, -rz..... Ul.� ?.'?'ZO i.,9-17 'tJ - I'?� Z3LfS 10�11 la-t'L10-i1rO-i'.2-. JO fc'J-l'L tJ..-1� cu,.Da l'o� '� 10--1'? [()-{,Z 0015. IA 00 '(O \c.,,- ,� a:::; YI Jo -J? Oll 3b /t,-/2 to-n rJ/t../( O'J1JV I (0 '//1 o'l,/"5 It).,.../'<:. 02,"',·.,, kJ...:.12 f( ...... r-L_ fd -,-z,,,,,, l�-� l{J-vz... o-rz... Code and signature reqll.lred on the above time lln•J per level of ob1ervadon. Jniti b)(6);(b )( 7)(C) Print Name Rtw: ()2/2014. 0512017 lnif b)(6);(b)(7)(C) (b)(6);(b)(7)(C) Signature Date Time Suicldtt Watch LoRINotes Form# HS-207.5 2020�1cu-00006 381 /-< .. 68@ smCIDE WATClf ., -1,J �ND NOTES TheGEOG Date: '/-.3o- / 7 Unit: trunatc/Detainee/Resident (I/DIR) Name: Inm1te/Detaincc/Rcsident 0/DIR) Number; 2- 7 B �q g"' '2/fJrr, M Shift: ·Location: I �2.? Check appropriate level of observation: Leve) J Level 2 CJ Constant Observation l'§il Fifteen Minute C�ccb Restraint 'i)pc: _____________________ Items alhnml (_.eek apprapri■le � QD � Suicidlll Blanket SQicidal PiJfow- eoa. li.::sDIH■tioD J. 8eatina on door/wall 2. YeJlina QI �rut 3.� P. Wllkinfl! Jo. LYii111! or mttina J°l. Quiet. J2. Slemin1z J3. Mcall"1Wd/� I◄. Fluida IOM!dhakert J.S.. Bdl,'Sltower 16. Toilet 17. S.mokiu . II. R_,.ints' . J9. Ram'e ofM�tion !2D. 01.ber 21. other 0 Other: V&a■I Tin,e Clltcks Made OJI J/IJ/R nme Code Code I Jnlti■I� Iraltills to ., b)(6);(b)(7)(C 110v l.lflW b)(6);(b){7)( o,, 5 ID, Jf"lt,1/,f.,) Ht<' 11,0 kl/ff 0-l,?P ,.,, . 2 e>{, '-I .:s '/tJ II H'iS" fO/H r-tUo 10/lf I 11">65 7 /n' ":i tUf Ju/h '616/ lb! -z.,. IL"J"'7/0 /ll � /2jO /(f/ /,1 ,..._ I Time A.,'.-.1_ ,4. Olnim 5. Laaa.1bim . 6. �.IJblml' .. iilcolunnlly 7. M · . . .. . . rtill 1 B. Under�armmts S11icide Mattress Bo0k ! (> 7·,-s iO{ l-1 1-0111 J61S ''-loo I 10/11 /JI/ O'loo /000 t:z.K ,.'J�o IJ'lr- JO/ H OSL/5 0'13CJ Clq'/5" ' 'W,,f)CI 10/' II JO/ ti o�,, c,B:,o 0.11,5 L.:H< /IJ I 'L 0"1:Jd (r'1,l/t; oBt,o -- In in •I '1-- (L I- 12-1 I 4IS' 10�11 IO- I I 1515 lu-JJ .Kt;f' �0-11 /tl-/1 4)o I 0-, 1 1./4!'"' In n,o Jf)-11 t0/11/ JO/II VO/II/ 10/IZ/ /0/1(//'I I 5":Jo /a-11 /0/J.f/ lo/ /7_ IOLf..r' - /�(1() Code and 1.lgn1ture requJred on the above ftme lin•J per levil of observation . Irutials: �♦siff�i ., 1nit:-1- ..... 11t1t-• b)(7)(C) b)(6);(b)(7)(C) (b)(6);( b)(6);(b){7)(C) b)(6);(b)(7)(C) l have reviewed the above Jog a11d certify thal for the shift noted above, the J/0/R was observed in accordance · wjth the requireme (b)(6);(b)(7)(C) S�pervisor: (b)(6);(b)(7)(C) Print Name Re11: �.2/101-1. 0512017 -L--------� Signature .... /(Zr.I Date Time S11lclde W,;tch Lo�/Notu For111 # HS.J07.5 ,,. 2020-ICLl-00006 382 - - l_ SUICIDE WATCH {.J.., AND NOTES. ---��--- .. ------ .. n,• GEOGro Date: J)�C. OJ 2,,,t;>/ Unit: Inmate/Detainee/Resident (I/DIR) Name: SJle: CZJ s2-7 Level 2 Fifteen Minute C.hec.ks _________µ_,_/.....A..;__________ Items allowed (check appropriate box): µI Shift; l � Location: IS CJ Suicidal Blanket Suicidal PiJfow COde �nl■■■doa l. Bc:,IIM on door/waJJ 2. Y1tllim oi . 3. CMn.it 4. CUn• 5. Lau1hillll . 6. SumilUt 7. •.- . .iiacohmnrlv stiJf 8..:;; 9. Wal.liiM 10. L'IIW! or 1ilhml JJ. Oufllt J2, SJea,mit IJ. Mais se,vs,d/�ce11 .. .. I Suicide Mattress Book Time /� t'..fo c) t'.J/ .f ! /.5""16 li.-d-d /61� /t,#() /(1.Jt;° Undergarments Other:· Vfl•al Tin,e Cbtclcl M■de cm1/J)/ll Cocfo I l11iti1ls :J.;$�,P 26( t; J/j.., l'J �5 MM, /.1, A/ 1,5 /2, /"t- 1-:J.... 17'1.� u. Flllick-•...:.L ··1t11 /'l'IH I J?/� I,. .B•th/Sliower /f'rd 16. Toilet 17. Smolcillli! I;'),'1� 18. Jleamn11 trioanod 19. Ranare ofMQtion . /9/k-J J'I/ $" I<1'1l'I It &bar 1. Other }?-, IA �7d 1.Jb& /2, - JnitiaJs (b)(6);(b)(7}(C) .... /,;, -2.1-n /� �::i.(!lJ /a J'// J/¥6 l.1"1-l11 f/b/// /7,:J,6 Id'� /� 17/.� I '3 I +c9Co( ,��I"\ Code I 'JJme /c. b)( 6);(b)(7)( I O f.J) /" /I 7;) ';( /A' ;z;/.f� I ',,,L I� I /1 ::,Z?.-h,' /.2 ,;1:J ?l. Id .a..�� /6 /2.. 1-'- � '::t.:lr. '.:'l.�"'5 /?,. JD J'l:> '2.. /6' .,,J "->06I /()' jl l""lo'"<>- / ,)!, /(\ I.I') 0'-/"5;. 12' .,,,..,, //) oos� fa. 1'6 I- II /,., ,JI /o.'/I /6;1" Code and 1pature nquJred on the above dme JI�•} per level of observation. b)(6);{b){7) (C ) I have reviewed the above Jog and certify that for the shift noted above, the l/D/R was observ with the requirements of Jevef of observation. • Sµpen1rsor � (b)(6};(b)(7)(C) Rev: �212011, 0512017 Print Name I 1------- b)(6);{b)(7)(C ) Date Dl3i Time Suicide Watch Lo1/Notn Form# HS�J() 'J.5 2020-ICU-00006 384 Inc. Unit; Date: 1-3o - , -, I,unate/Detainee/Resident (I/DIR) Name: .SC41V'�...,_,. r Inc. 'llteGEO _ Inmate/Detainee/Resident (l!DI.R) Number: 2 2-73ol '/ It Shift; 6 Location; S:2..'7 Check appropriate JevcJ of obseJVation: Leve12 Leve) l Cil. Fifteen Minute Checlcs Constant Observation □ R.estraint Tn,e: -------�------------­ Item• allowed (dleck appropriate bos): Uodersannents EJ Suicidal Blanket CSI Suicide Mattress C] Book fB1_ SuicjdeJ Pillow Otll�:· C,o;cle ln.DlaHtioD l . St141tina on doorlwaJJ ID 2. YaJlineot · 3. erwi. •· eunw 5. IAJ.llhilll .. 6. SimrlnR' . iiacohmmtly ?. - • . . 8.. stiU 9. '":.. ··:..... I 0. L\liu or aitiin IJ. Oufet. 12. Slecmimt!' lJ. Me.ills ICrWd/�lea I◄. Fliaid1 �ken U. B�howa- J6. foflet J7. S,moldmr ' 6//5 Jl> / 0/ 1./5 '*' e/a_'i{ JI. R8trllmll 1 19. �ofMO.UOD fl.Other J. Other- 111/t;..,,._., ,.,: ,J /6 .,_ C,�< /6 4-..'"' ,.� h!l.-£Y 1"'�'2... l'Y.l.rl.� ' ,1/ 6'2.. I.it: /t,i ' JnitlaJs I b )(6);(b)(7)(C) ✓b�II b2"'l:> "".i 2.. L• ✓Lf Jc, It D)� JI ......,.u'° IL" ':2 ,'°t;7 ;f� �,5 �'12.b JI Jfj J/ '2.. �JV� i /_J. ,, h,',"gi:) . v11.-.1 TI.aie Clltclll M1de OJI I/DIR nmc Code Inftialr Code Time '2 /�II '2... or.., s J6 II 7...;� �· ...,_,:-2L:> ;-,�3� JU 2.. .,. , r.J/./S id /I oS.S7 1t>:I /f Code and ••1111ture requJred on the above dme Ila•} per level of obaervatfon. • I ft"Sionah1tt )� r6);(D)� l1---1 r··l��li!�i j S!ttr§iro•nw I I Wi!ial• I J have reviewed the above Jog ar:,d certify that for the shift noted above, the l/D/R was obse,ved in accordance with the requireme t ation. b)(6Hb)(7)(Cl Sµpervisor : · (b)(6);(b){7)(C) Date Print Name Rev: �211014, 0512017 ... ,, 2020-ICU-00006 385 Time ,--<. I SUICIDE WATCJ\'-- ..:.., �ND NOTES mmatc/Detf,inet/Resident (I/DIR) Name: Check appropriate level ofobservation: � Level J Q:g Constant Observation [;I Ratraint t:we: L Inmate/Detainee/Resident (JtD/R) Number.: ;z:). 3�0, f fr Shift: Inc. ·1ocatio� '5t?< LevcJ 2 Fifteen Minute Checks _M ____1ff _______________ Items allowed (dleck appropri■te bo11:): SuiciO 14. Fluids_ .�':-!.·en U. B11tb/Shower 16. ToiJct J7, Smokiu )8. �iats Loosened 19. �eofMO,li011 0. Olhor 1A;c.r--, f"l,.,,i.s 21. Other /0 i/?./'7 , Z../s /U.,S"" /'2..2.o , -z.1...5' /.Z.jt) llJ.$ /z_ 7?1 /7-Yf / () l'L ,7 I 'JJS /,e:, /� /¼r-- /0 / 7'/..r ' 0 Vy 2.._.J /,Y2"' Z.:> Y.ro /0 Code and signature reqllired on the above time ll_n•} per level of observation. I hbX6J,(b)7( XCI St■f£o;-�.. · -----ti�� bXlnili1l1 ,);{b)(7XC) I1--F I � ; -z_..- /{ /0 /1/.r.,,? 1-i.:.1. 1-Z.. -1 � /tJ ('o I b)(6);(b){7)(C) - ,,-z__ I 1�3,;.. J�t..tl".) ·,-rr- o r'o /0 17.__ I� l�Li5 /{) Coat r? I '1Ttl /t, ' 17" -=- /?z_O> /J7X' /0 11r I "l.Sf J-:f/.S /0 /#'?---� 1/fo r 12. �•-- ' /y, 11"'1> nme { 'L,S 0 1joj" /J/o ✓ () // :J.-> .. ") /IP /1-Z.5 I ;fo lliJi 8.. $>. Wallmur J 0. L\IUIR or lillin11 JJ. QufDI V&.ual Tirue Cllten )fide on J/J)/lt J 1 C)" 3. Crilwr 4, I 5, LluduD.li! 6. Sutl!ina' 7. M · - .. .iocoheten1Jy Code I loitil s 1 ()_ b)(6);(b)(7)( ' 10 ' I') /0 /Q t"'6 �e /o ,, ,,,..,, /v /t) Stu[Sjpllm:s : Jnjtilll• ------------+1:-----j:I I have reviewed the above log ar)d certify that for the shift noted above, the 1/D/R was observed in accordance with the requirements ofleveJ of observation. Supen,isor (b)(6);{ b)(7){C) R�v: �2/11JJ4. 0512017 ame b)(6);(b){7)(C) -L------------- 11/-Jaf l8ignature .. Date /I c?!J Time Suicide W1ttcl, Lor/Notes Forn, # HS�JO"I.S 2020-ICLl-00006 386 ( SUJt:;JDE WATCH(·� J �ND NOTES Shift; I J, · Location:S 1-:/z. Date: //- 'l.."1 -11 L Unit: /VJ.€{; . Inmate/Detainee/Resident (]/DIR) I,unate/Detaince/Residenr (I/DIR) Name: .SA f'-'\/V\ �J 'Z. °l I g>Number; z-z...., Check appropriate JeveJ of observation: Level 2 Levell c:il Fifteen Minute Checks &:131 Constant Observation _//l.tfl_ �_ ---------------- Ratraint Twe: e Items allowed (clleck ■ppropri■te bo:K): Suicidal Blanket CB Suicide Mattress C] Book f!S SQicideJ PjJfow Cc)de .E.nlanadon l. Sc,ilbu on door/waJJ 2. Vallin&! ot · 3.C!Yina 4. Cunw. 5, l.apJrbiu ! .6. Sbhzint . 7. M · •., B. - . .. 9. Wllkill.a iocaherently 1tiU JO. LWUE or 1ilttng U, Qu.ior. U. 5Jemine Vl111al J'ln,e ·cbtc,C. Mad, on J/1)/ll lime Code J Initial Code Time 07',t) 0'7'/5 O?.f'O 07S.5 onoo OY?JS· I'> f.lo o.rtJ' C, � ()� In tTO �.J' I 'l_ I 'Z,.. /Z./ u ()er<,\ Olb.l '71\1 Uv-r l"t-<.J� O'i/o o '1 IS 1cu,5 IL 17. Smokuur JI. .RatraiDtt 1.oo&enod JSI. lwuteofM0.1ion t)"J(1J c:,fs5 [/0.!PO IL I ').._ 7AIA:J-"' w I µvr-7,._ C7/f'o IL... (}yl.f, O.Yfv Other J. other- /C> /0/j' n-.. r"'- /0 •? /0 Io t/0 I/l I /') IQ�� I I(J() ,,;c;n /.D /'O /o J0 /'O /2-. /0 1-r \"I.{!; I /0 I 030 ,-;;z..... IRi.;..1. /() IOZ.0 iI,) 'l, t::, IJ-· rz..... J (b )(6);(b )(7)(C) /0 /o /r, /o'l, I"- 2.. &'f'1. e> t9'fY1..F t:J�5() /2.... 13. Mella ICrVCld/catca J◄. Fluids �en 15. SathlSleowv 16. foUef b)(6);(b)(7)(C) /'Z_ /� O{('-¢u Undergannents Other:· JI) > () :..Z/l 8../) Code and 1ignature requ.Jnd on the above time Jin•} per level of obaervation. Initi ni (b)(6);( b)(7)(C) b)(6);(b)(7)(C) J have reviewed the above log IU)d certify that for the shift noted above, lhe J/D/R was observed in accordance with the requirements of level of ob b)(6);(b)(7){C ) (b)(6);{b)(7)(C) Print Name Re11: ()2/1014, OS/201 '7 Signature ·• ul'Zlt r r/,1-1;1 rr Date Time Sulcid� H'titch LoRINotu Fo,,,, # HS-207.S 2020-ICU-00006 387 ftwGIOG Shift: 3r; Date: \ \-1..C,- ll Unit: f<\e � o.\ InmatelDerainee/Residcnt (I/DIR) I,unate/DetainedRcsidenr (I/DIR) Name: Number. '2., ""L1 3 LC\ \ 1 5°'""'M: r>,/' Check appropriate JeveJ ofobservation: LeveJ2 Level J c::I Fifteen Minute Cllcclcs Constant Observation Cl[' _,_)J_{A'-'---------------- Restraint type: _ Items allowed (died< appropri■te boJC): ll2J Su1eide Mattress Suicid.t Blanket Book SQioid■J Pillow □ (El [IJ Code £spla■1doD l. Se,iw on door/waJJ ., v,JliMw 3.� .. 2. 5, La�ahiu ,. � 8. - P. � . .incoherently .. .till 11�11..e�- I 0. L\liiur ouittine: u. 12. 13. J◄. 15.. 16. Oult,t. . Me.tis scrvod/eateri Ftwd1 wvedlt.ken Blllh/Sbower Toilet 1'7. SJGOldnrz 18. Rtmnaints Loo1ened 19. 1lnlre ofMt11KJn 20. Other J. other .� .. \(.. b)(6);(b)(7)(C) •fl'<' Ol.otl Ota� l"'L •• �� ! v,r■■I Time "Clltckl M■de on J/1>/lt I Joilialt 'Jimc Code Code Atl'J 0 4. r-.-:..- . 6. Sinmlt Time d-Ho 04\S Undergannents 001�:· .. •l.4...11'\ nl.4.V- othl-r, �ll..- ()&(,� /JI.I.� M.t,r i n 1LtJ '"-.eraince/Resident (I/DIR) Number; Z.,__ "=1,- 3 2 'I I I lac. sz Check appropriate level of observation: Levol J Level 2 182 Constant O�s7ation [.I Fifteen Minute Che.ck$ Restraint Type: _;tLL...&.,#--1/A--.__________________ Items allowed (check 1ppropri1te bos): 183 Suicid41 Blanket � Suicide Mattress BJ S�icid■J PiJfow CJ Book l. Bcatin1r on door/wall 2, YcJlin• � ;c,ea.min1t 3. Cnlin.it ...., .....,,, . -'LI I c.. 4. Cunuv 5. La:uirhim 6. Somnt 7. -.- , - •> .iocoherc:ntly -i.i'2-.r;-- "1-(°?D ' ""t...1�5'" '? I 8. . ..........:...- 1t1U "· w�illdile ..../Q 13. Meals �qleo U. FJuJd• lffl'IICiltaken 1$.. B111h/SbowaJ6. Toi.let 17. Smoidn11 . J 8, _R-,,.iats I ISi. � ofMotion 20. Other AA.c-,.,,c.\ ..,r- � Pi>N\:( 1. Othar 1.-Z... ;;j "L-;a.,-... ,7-t,�� Ztt..Llo '2-i---1.:, '7..-1-� l � IMI r'\ ...o 1) 'lO oz;;' l)hl1) I f'\ M\_t;° lo o ll"f" 101n �'\C- /o tlOt.10 lo lo lrJ. IL - ,� fl) I�� � I,,.., , ,.... r.. l'81o 9-�t 7} la (b i;J ( I'.'.'\� ,'Ulo (� It) I ,._ .,{� lhO ;n�15 (O '2. '"ti� --z.., ?-, .::1•11< 1 LI -i...-i..o-, (0 o, ;f','7\ '2 lo "2.."Z7. 0 'L'( •1-z..._ I ,z_ �, <""'5:'° {) .::, 7...71� c..-Z..c;5"" 21..,•,l\ :2 ID ..,..., ll. Oufet J '2- 1..1 '+� �(C,0 JO. 1.\/iiiur or Bittma 12, Vl111al Time Cl11icb 1'f■de on .I/Dill Time Code l •-��1. � Code I Joitial1 b)(6);(b)(7)(C) b)(6);(b)(7)(C) Time "Z-110 Code lbeluaHH Utadersarments 011>,:r:· J. �1 ID 'ti 10 In l {) .re, fQ., Code and 1ign■ture required on the above dme Hn•J per level of ob1erv1tfon. ni. b)(6);(b)(7)(C) (b)(6);( b)(7)(C) J have reviewed the above Jog �d certify that for the shift noted above, the I/DIR was observed in accordance with th e requirements of JeveJ of observation. Supervisor l (b)(6);(b)(7)(C) ---i Print Name Rev: 02/20U. 05/2017 I1----- (b)(6);(b)(7)(C) 11/4£19 J Signature ·• Date Time Sulcid� H'litclr Lo�/No�s Form# HS-107.S •,• 2020-ICLl-00006 389 I 1 . smc;IDE WATC.Jt/�-.., AND NOTES Unit: Date: bt,nate/Detainee/R.esident (I/DIR) Name: �M . etaince/Rcsidcnl (l/Dffl) Number.;Q(:}.n, Check appropriate JeveJ of observation: Lever 2 Lev1:1J J � � Fifteen Minute Checks l!:l Constant Observ.tion Rema.int Type: --'-�_/2_,_�------------�-- Items allowed (check •ppropriate box): E] El Suicidlll Blanket Suicidal PHfow . Ef Cl l!J Suicide Mattress BoQk 0 Updcrgarments 0th�:· l. 2 3 4. 5 .6 14. llids .-vedleaken 15.. B�bower 16. ToUot Code and 1f&n.1ture reqll.ired on the ■hove time lf_n•J per level of ob1erv1tlon. J have reviewed the above Jog �d certify that for the shift noted above, the I/DIR was observed in accordance with the requirements of JeveJ of observation. b )(6);(b )(7)(C) . Supervuor: _J (b)(6);(b)(7)(C) I ..r------- - L______ Print Name Rev: �2/2014, 05/2017 Signature Date Time Suici4� H'•tch Lo�/Nores Ftmn # HS-207.S ·• ,. 2020-ICLl-00006 390 £11/orcemem and Removal Operations lJ.S. Department of Homeland Security 12445 E. Caley A venue Centennial, Colorado 8011 I U.S. Immigration and Customs Enforcement l December 11, 2017 (b)(6);(b )(?)(C ) Highlands Ranch, CO 80130 Dear Mrs. b)(6);(b)(7 )( C) I am writing you on behalf of U.S. Immigration and Customs Enforcement (ICE) and regret that I must inform you of the death of your brother, Kamyar Samimi. I extend to you and your family the deepest sympathies of our entire agency for your loss. Your brother passed away on December 2, 2017. The preliminary cause of death is unknown at this time. In order to ensure that all of our uestions are answered, lease feel free to contact Field Office or b)(5);(b)(?)(C) De u Director of Legal Director Jeffrey Lynch at (b)(5);(b)(?)(C) 5 C) ) (b)(?)( (b)( ; Affairs' Iranian Interest Section' Embassy of Pakistan' at Please accept our deepest condolences for your loss. ice irector Denver, Colorado 2020-ICLl-00006 391 ICE - Significant Event Notification - Significant Incident Report ICE Significant Incident Report Submi tted Date and Time of Report: 12/3/2017 1703 EST Incident Date: 12/2/2017 Incident Time: 1202 Incident Locati on: ICE Component: Enforcement & Removal Operations Division: Field Operations Division Area: Western Operations Case Number: No Case Involved Office:WD - FOD DENVER - DEN Lead Agency: B - DHS / ICE Inte l Number: ENFORCE Number:.... l MAIL ( ) THIS DOCUMENT WAS SERVED BY: r J �ATT/ru:� Officer Cu,s.u:>.Qial c/o ALIEN ] [ ,+,.ALIEN [ TO: ntt.Ti:::- \1'.LC:.._IF"l RV- rnT���il,.!,900063S4 � ·, ii I �G: SAMTMI, KAMYAR f'I:E: 022-732-918 TC: KO:' ICE 02' ::EAR=l\'G IK ::.S.EMOVA:.. PROC?,E::IKGS :'.:Y,11:=G?.A':'IO:,J C:0'.HT 3:30 N. CA�LAN) ST. ACRORA, CO 80010 DATZ: Kev 22, 2::::7 SAt.-:=v.=, KAf.::YA::.S. Cr.S/ICE/S::;O 3l30 N OAK�ANO STREET A:..:rora, CO 800i0 ?lease take :1c:ice tha: :r.e above cap:ioncd case has been scr.eduled for a :'1AS'�E?- hear!r:g oefore the l::t.'Tl!gratio:1 Cc·Jr-t o:-. Dec 12, 201·1 at 1::::0 P.J:v:. a~· 3:30 K. OAK:A�D ST. ACRCRA, CC, 80010 Yo� may be represe�ted !!:. :hese proceedings, at no expe!:.se :c the Governrnc�:, by an a:tor�ey or c:r.er ind!v!dual whc is a�:tor!zed a:1d qual!�!ed :o rep.::-ese:-:t persc,r.s before a:1 =:r.r:-.iqra:i:n: Co1..:rt. Yo:..:r heaY!:"'.g date :1as not been sched:..::ed earl!er tha:-: 10 days from the da:e of service o� the :,Jot!ce to Appear in order :o per�i: ye� :r.e oppor:�:1i:y to ob:a!n a:1 attorney or represe:-:talive. If yo� wish to be represe�ted, yo:..:r attor!:.ey or represen:a:ive :r:..is: appear wit:'1 yo·:. at t:--.e l:eari�g prepared to p::oceed. Yc·..1 ca:1 req:iest an ear:ier tearing in wr!t::.hg, F2.ilu::e to appear at yo·:.r heari:1g except =or e.xcep:ior.2.l c::.rcW'.'.stances (ll You �ay be =aken i:1to �ay res�:t in o�e or reore o� the fol:owing ac:ior.s: c�s:ody by the Depa::tmer.t of Ho�eland Secu::::.ty a�d he:d for further act!cn. OR (2) Yo�r hearing �ay be he:ct in yo�r abse:1ce ��der sect::.on 2,0(bl (S) o: t�e =�nigrat!on ar.d Ka:ior.al!ty Act. An order of re�oval w::.l� be er.tered agains: yo� i: t�e Jepart�en= o: Eo�ela�d Sec:..:rily es=ablished by clear, �neq�!vocal a:1d convinc!�g evidence :hat a) you or yo�r attorney has been provided th!s �otice and b) yo� a::e re�ovable. IF YOCR AJDRESS IS KO:' �ISTED c� T�E �or:::::E :o AP?EA?-, OR!? IT IS KCT CORRECT, wn�:rn FIVE DAYS 0? TEIS :JOT:::::::: !"OC MUST ?ROVIDE 1'0 THE r:-w.:::;AATIOK CCJ::l.T ACRCRA, cc TEE A7TACEED 1:·cR.:1 :::o=R-33 WITH YOCR A:::ORESS AKD/Q;,,, TZLE?HOKE :,JC�JER AT WHICH YCJ C:A:,J BE CON:ACTED REGARJIKG THESE PROCEEDIKGS. EVERYTil'-'!E YOJ C:2AKG::: YOCR AJD?-ESS ANJ/CR TELE??.OKE :--IC:-'.3E?-, YOJ Y:t;ST IKFORM THE COCR:' OF '.:'.CU?. NE:W A::mRESS AKO/CR TEL:.:Vi:'.JKE :-..JCY.3SR WIT:-!I� 5 !)AYS O? ':'H:C, CHANG::: AJD:T=ONAL FOR�S ECIR-33 CA� BE CB�A;:,JED ?RO� 0� THE A:TACHEJ ?OR� ECIR-33. THZ COCR':' �r.ERE YOC ARE SCHEJJ:,EJ :o AP?EAR. IK '.:'HE EVE�� YOC ARE UNABLE :'O 03TAI� A ?ORM EO:R-33, YOJ Y.AY ?Rcv=os ':'EE COCR: =� WRI:ING WITE YCJR KE¼ AJDRESS JI.ND/OR TELE?'.-:ON'E :,JC:V:3ER BCT YOJ :-'.GS, CI..E.1'..RL!' JV.ARK 'l'EE ENVE:OPE "CBAKG� O? ADJRESS." CORRESPONDENCE ?RC� T,�E ::::00RT, INC::..JJING EE:ARIKG :,JQT:::::Es, w=1:, 3E s::;:,i:- ':'O THE r:,,:cs: �ECENT ADDRESS YOJ HAVE PROVIJEJ, AKD w:1::.. 3E CO�SI�ERED SC'E'F'ICE:--1'.:' KO:ICE TC YOC ANJ :'ESE PROCEE:□=�GS CA� GO ?0?-WJ\.RJ -;-:,i YOCR A3SE�CS. A :is: o� free legal service prov�ders has bee� give� to you. For i�for�atio!:. regarding the stat:..:s cf ye�:: case, cal: to:l free :-BC0-898-7:80 or 2.:0-314-:so:. D�,S 23 0-:::::e:::- 2020-ICLl-00006 395 U.S. Department of Homeland Security Notice to Appear In removal proceedings under section 240 of the Immigration and Nationality Act: Subject ID: 359887663 . FINS: 1238805650 DOB: 01/03/1953 In the Matter of; File No: 022 732 918 ==== = Bven�t�N�o�:�,� ==.( ) )��)�E� lCAMf __ AA __ sAmXI Respond ent: __ _____________________________ Aurora,cotoll>.Do, 80010 (Number, street, city and ZIP code) GEO Detention Center 3130 N. O�and st. 0 0 currently residing at: (303) 361-6612 (Area code and phone number) l. You arc an arriving alien. 2. You are an alien present in the United States who has not been admitted or paroled. Ii] 3. You have been admitted to the United States, but are removable for the reason� stated below. The Department ofHomeland Security alleges that you: 1. You a�e not a citizen or cational of the United States; 2. You are a native of IRAN and a citizen of IRAN; 3. Your status·was adjusted to that of a lawful permanent resident on May 9, 1979 under __ .section_245,_of ,the Act; . 4. You were, on June 13, 2005, convicted in the Arapahoe District Court at Centennial, co for the offense of Possession of lg/less of a Schedule 2 Controlled Substance, to wit•: cocaine, iD violation of CRS 18-18-405 (1), (2.3) (a) (I). On the basis of the foregoing, it is charged that you are subject to removal from the United States pursuant to the following provision( s). oflaw; See Continuation Page Made a Part Hereof 0 D This notice is being issued after an asylum officer has found that the respondent has demonstrated a credible fear of persecution or torture. Section 235(b)(l) order was vacated pursuant to: DSCFR 208.30(f)(2) O8CFR235.3(b)(5)(iv) YOU ARE ORDERED to appear before an immigration judge of the United States Department ofJustice at: Denver Contract Detention Facility 3130 N. Oakl.and St. Aurora CO B0010. BOIR Aurora, CO (Campleu Addre.ss a.n. 0 '1, 2nc: retu::nable on cie ��10 = Judge Deienclant ordee-ed booked and released_ l -·· . ": . I - ., � Judge 2 2020-ICLl-00006 405 ----- . People v. KA.'1YAR SA...'1IMI ---------- --- --- --- -------- ------ --------- lnistri�t A:tomey or the Eig1:..teenth fodicial Distric:, of the S:ate of Colorado, i:l fbl(5);(b)(7)(C) f ':he name and ':Jy tJ.e aufuor:.ty o: the People of the Sta:e of Colorado, informs the court of 'lie fo:io�ing offenses c:,m:::litted, or triable, in ile cm::nty of Arapahoe. COl:"NT 1: POSSESSION OF A COI'l'TROLLED SD"BSTA.KCE - SCHED"C-r.E II - 1 GR.\M OR LESS (F6) On Febr;1a-y.·08, 2004, XA_l\tiY_..\R SA.lv.fIMI un.:a-vv-f.illy, felo:iiously, a:ic. knowm.gly possessec. o:::i..e gram or less of a matcia:, compou:id,.r::i.i.xv.r:-e, or prepara:ion that co::::ainec coca:ne coca leaves, a schedule Il controlled s-i::Js:2:1ce; in viola:ion of section 18-: 8-405(�),(2.3)( a)(I), CRS. AJ. offe::ises against the peace and digni:y of the Peo:?le of the Sta:e ofCoiorado. (b)(6);{b)(7)(C) 3. 2020-ICLl-00006 406 People v. KAMYAR SA..."l\1.IMI f .... b><5>;la:i.:it/ iI:forma'ion, here:o attac:::ied are '::::-ue a:ic. that 6e o ::fenses there:.n charged were cor:::rrn.:tted of tbis aSant's O-'T. persona:. ko.owiedge. (b )(6) ;(b)(7)(C) l S:ii: scribed md sworn to before ::ne i:J. �;4Arn;iahoe Com:y, Colorado. (b)(6);( b)(7)(C) xprration Date: lz'-/ �oo ✓r District A'::t:o□ey's Office Eighteenth Judicial District · 2020-ICLl-00006 407 ; People v. KA..l\1YAR SA.MD1I WITNESSES fb)(6);(b)(7)(C) Al}ROR.-'\ POLICE DEP_A__��'T 15001 E/i.LA1.\ffiDAPARKWAY AURORA CO 80012 l(b)(6);(b)(7)(C) AL""RORA POUCE D3PAR�"T 15001 E ALA.MEDA PAR.V::WAY Al:""RORA CO 80012 fb)(6);(b)(7)(C) ACRORA POLXCE DE?ARTME:\'T 15001 E .ALk\1EDA PlvJXWAY . AUROR.A. CO 80012 tb)(6);(b)(7)(C) I AUROR.t\POLICE DEF ARDvf2'.l"T 15001 E ALA.lvIBD A J>_ARKWAY Au"RORA CO 80012 b)(6);(b)(7)(C) f AURORA POLICE DEPARTMEN1 15001 E ALA.\.IBDAPARKWAY A1J"'RORA CO 80012 fb)(6);(b)(7)(C) AURORA POLICE DEPARTMENT 15001 E ALA..\fEDA:?.AJD!:.WAY AURORA CO 80012 5 . J '': .. i - ' 2020-ICLl-00006 408 -�. ,. � People v. KA:'1:YAR SA.."1\1IMI OF?ICE OF TEE DISTRJCT ATIOR1\cY EIGRl'E.ffiTH :;L1)ICIAL DISTRICT STATE 0� COLORADO �OTICE TO: TIG DEFENDlL.'E .A}.."D HIS/HERATTO�-:SY � T:lli ACTION j< __.P ( )_(J_)(C_)___ CO:MES �ow, Lb-)(B-);-b ist:ic: Atto:::ney in and fort.he Eig:..tee:ith hdicii. Distric: and County of kapahoe, S<:ate of Colo:::ado, a."1d notifies the Com: anc. the defe:::idar.t oat �t!:rin the time periods ?rovided. in Rule 16 of t:ie Colorado Rules of. Cr.minal Procedure � oaten.al :-eq6ed to b� disclosed by Pa..1: I ofRule 16 of 6.e Colorado Rules o: C::ci.:ninal Procedure will be made available b y contacbng 6.e Office oft.he Dicict Attomey during normal business hou:s. All discovery req-1ests may be made in pe:so:i. at 7305 S. ?oto::B.ac St-eet, Scite 300, Centennia:. between the .!:lours of 8:00 a.rr. to 5 :00 p.m. Discovery will be prnvi.dec immediately 190n req11est. 6 2020-ICLl-00006 409 ... . I - . - - -- -- . ,, THE STAT!: OF COLORADO AY\ Alt -- ---�-- --- ----- ------ ;,fondant Aadress· k -.,e ada�ess of me o.-□tecte::'. party may oe omittec tnr:i the wrtte:i •Y0er o' the Co1..:r:. 1nc1uding the .,eg1ster o� A�o:is MANDATORY PROTECTION ORDER PURSUANT TO§ 18-1-1001, C.R.S. TO: ;::-- .S ao-,-. �-�C ,_--:!_'_ "-'"'1'--,l;-c---J",'-tc-- C-, c ,-���fet,.}t ==��=�=�=��� v = =s � ::__ � "-c-i H. i ' " c':;c -':O O B•· THE COURT FINDS it is a;:ipm_:,;-iat to i -ue this Prote.:.tmr o-□e� :,·J-suant to§ ',8-1-'881, C.R..S, Iha'.. i': '13s ju:isdic;i:m over the parties a�d the subJeCI rnat:e�; ?;;at e Defendant was pe�sor:a]iy served a:id g:ve� reas:inable :iotice and o_:,_:,:irtunity le !:le :1eard; tha� be D1cfenda:i'. constitJtes a c�e::!iole 1;1reatto '.:.1e ii'.e anc· health of t�e ;irotected ;:ie:-son\s\; an: sID:::ien'. �-Jse .ex'1s:s fry t:ie issuance o� a ?rotecli:in Order :Jnless the box inmeC:iately below is chec: .;:e:'., the Cci·Jrt foos 1:-,a: the Defendant 1s/was a� intir:iate partner, as that te� is 'JSe-:· un::ier 15 L' .S C. �9U '.C)(S) and (g)(8) of the B·a:ty Ha,1agun V10·,ence Preven:ior. A-:1. Ths Court fonds ':',a: !:le Defen::la!l'. is/was ncit ar intinale :,a-t!ler a:,d is no: governed by the 3rady Ha,dgu.�. Vb1ence Preve:11ion Act TI-iEREFORE, [TIS ORDERED THAT y:iu, the De1e7da,c: 1 S�.al: nci'.. harass, i�jure, moles':, intmi1::::ale, threa:er,, retaliate agai.7st, a; ta.T1p1o1 wtt'l any wi1:ness tel cir victir:i of the acts _ � yciu a.re c."larged w�. ccimmitt1.1g. D 2. s·nall vacate fne home of the v1cb:T1(s) a;1a· stay 3Vl.'3yfram any other lo:;atio� t'is viciim(s) a� witness(es) 1slare iike1y lo tie bu:ic. D 3. Shall ref:-air, tram co:itaCUng or directjy ci: 1nd'1 redly c:Jmmu:1·1�tl.1;i wit/"'. the victim(s) o; witness(es;. S'ial: not _:,assess cir contrci; a firearm :ir other weapon. Shall ,7ot possioss or car:isJr.ie a1ccih::ilic bevera�e� :r c:J:,lroll s:! substa:-ices. � 6 IS'FURTHER ORDERED THAT: ____________________________ cg : J 7ne names, dales ::i7 b1r::r., sex, and race of the prnteded ,:ie·s:ins anc:' any vi::tims orwitnessss a�e: �1is Order ,emains i� sffe t 'Jntil fina: d1sposit1ci.1 or-f1..rtr-r oroer oi Court.* 1 3y Signin,;lf Da�e I certify /I t.",i1 ; �/7J-1 resE:ijJI cif this Order. 1s a trus a.'ld corn;:ilete ccipy of the o.igina :i,osr. Date: __________________ C :.idge C Magistrate '.Jefenda:11 Cierk � j (-.\:\v PLEASE NOTE: !MPOR'rANT NOTICES FOR RESTRAINED �MnES AND LAW ENFORCEMENT OFFICIALS ON REVE'Rse! ...Unfil lina: dis_asilion of lne a::Uor: means unti.' lne case 1s disr:iissed, until the ::lefenaant is acq:.irtled, or until t'le D1cfenda:1t completes �is/her senten"8. Any ::>efe .1dan: sentenced to probatron or in�=:Etbn sh3I! ae dioemed tc have comple:ec" h1s/ ,1er sentence upon discharge from probalia� ar in::arceration, �s the case may be.(§ 1B--1- .1qo·•(9/(o;, C_R.S,) JDF 440 Rl/04 MA,'IDATOR.Y PROTECTION ORDER PLbU�-fttlf-� �"1&91 <>f 2) DIS7RICT COURT, ARA?AHOE COUN'!'Y, COLORADO 7325 Sou'.:b. Potomac Sr::-eet, O:::ite:::i:-ial, C::ilorado 80: :2 (303) 549-5355 Filed in th� Div. JUN - 9 2005 TH5 PEOPLE-OF Tiffi STATE OF COLORADO Distr1�� C□un Arapoirne County, Colo. A COURT USE O'.\T,Y A CASEC\TMBE?c Ok/L ic/3r Div., d.-Cl "/' PLEA AGREEMENT OF THE PARTIES TH:: DEF::�DANT HAS AGREED -;-o PLEAD GU'LTY TO COU�T(sr ,ct:c.1--d]<"1'2.'µ:.0'>h.Hi!c!'-J£""-Jd_ ,.CTED BY ____________ 2020-ICL�-00006 411 The People of Colorado vs . S.AM.IMI, !.efore the CotL--t for entry of jud.gmetlt �pon the :-equ.est of the parties, a.-ri.d De Court being advised in the :;:>rernises hereby enters judgI:!len.t for T::ie Peo:;:,le of the State of Colorado _____________________________ and against the Defend.ant k�4k/L �.M. � for the unpaid financial obligation mmai::1lng in Dis case from the Court's previous orders, in the . principal amount of$ _f·..._"""&,__.....L=--·..,J,£"_C_______ Post-judgment interest shall accrue ;is provided by law. Done tbis _0_O Court Ac'dress: ?ho.,e N urn ber: Arapa:1oe Courty j·.Js:ice Cen�er 7325 S ?o:o:-nac St Cer.tenn' 0112 b)(6);(b)(7)(C) - COURT USE ONLY - 2J04CR001437 The People of Colorado vs 204 SAMIMI, KAMY AR SEN I ENCE ORDER Defendant: SAMIMI, KAl'✓.YA.9 Date of Birth: C: i/C3i1 953 Count Ctass Plea · . i:::� � : 8-; 8-405(:) ,(2. 3)( a)(!) - Control lee s:Jbst-?ossess s::::-i 2 . o Plea cf Guii:y 2 18-18-�28(1) - DrJg· Paraphe"naiia-�ossess PC2 ?'ea of Gi..:i!ty ASSESSED FINES & COSTS Count# 1 . De�er�ec: Sen:ence REVOKE!J: 2 Years Al:::o!iol :=va: Fee ::ommu:,ity Servi:::e: 64 Ho:.irs .�i;q-Jest :or Ti:ne to =>ay Cou� Cos:s - T, M, C� VAST r.-.in �or o"f af:er 5/1 /03 Victir:1 Co�pensa:ion . .:und Offender Identification F:.md Count# 2 CoJ� Cos:s - T, M, CA TOTAL Finding G..iil-:y _Gui'W $ 18; .00 $25.00 $35.00 $1 62 50 $125.00 $128.00 $ '. 00.0C $756.50 Other Conditions of Sentence: F=LONY CONVICTIO,'\ ENTERS. PROBA:ICt-. 1S 7ERMII\ATE:J UNSUCCESSrU'...:..Y. NO ;:J:'C-�ER ..:Ail IMPOSc:D. COSTS AND F::::S ::::otNER:i:C TO CIVIL: n:)SM::NT. CASC:: iS c:.osE�./D9 I SAMOU�, CARLOS �� . Judge/Magistrate 03/06/2009 Date 03/06/2009 Date •••••••••••••••••••••••••••••••••••*•••••••••••••••••••••••NOTICE*•••••••••••••••••••••· SAMiMI, KA1/YAR Defendant Fo!lowing t�is hea6ng yol..! a�e :o prese.,t this'forrr 70 :he Cle,'k's OVi:;e b, .:iay:ren".:. Payment is due by tr.e end of :iusiness on y:x.1r Cou:-t Da-::e. Fai:ure to ;>ay when d:Je wil: resul-: i:-. additionai costs ;:,:.irs;.;an: to i-,'31198. 11 2020-ICLl-00006 414 .i. \ IN THE DISTRI_CT COURT IN AND FOR · THE COU!\'TY OF ARAPAHOE EIGHTEENTH JUDICL4L DISTRICT . . STATE OF COLORADO STATE OF COLORADO AR.PJ>A HOE COU)J'TY CERTIFICATE OF COPY rl..?AHOE COM3NED COi..,"RT Bv: ., l(b)(6);(b)(7)(C) D.r>putyClerk 2020-1clt-oooos 415 _,,........_ I Colo:-ad.o Cou..-t cf Appeals 101 West Colfax Aveaue, St:�te I Denver, CO 80202. ; i �• . bl(5).(b)(7)(cl .:...r ,: �; r { � 2; i it ! = =;(;= k=L-== = = -.l..�\,.�ff'< _ ....... :;;:-...... :u...r,:; ;-:;; ...... ---,-. 7 � :;'f I A°l\ID .. I kapahoe Coun:y __, _37 l ____________ R 4 �!2_00_4_C__ : Plafuti!f-Appellee: 1 0� : BY i The ?eople of the State of Colorado, -9---/4--�-_-/-/�- I Court of Appeals Case I I I N�ber: I Defend.ant-Appellant: I 2009CA820 I I Kamyar Samimi. I Iv. I MA.i.�"DATE This proceeding was presented to this Court on the record on appeal. In accordance with its announced opimon, the Court of Appeals hereby ORDERS: ORDER AFFIR.\1:ED F THE COL"RT OF APPEALS (b)(6);(b)(7)(C ) DATE: SEPTEMBER 20, 2011 I. 13 2020-ICLl-00006 416 COLORADO COL"Rf OF APPEALS Court of Appeals ;'.':Jo. 09CA0820 Arapahoe Cot:nty District Court !'Jo. 04CR1437 Honorable Carlos A Sam.our, Judge The People of the State of Colorado, Plalntiff-Appeilee, V. Kamyar Samjmi, Defendant-Appellant. ORDER AFFIR.'f\-1.ED Division ID Opinion by JUDGE DAILEY J. Jones and Lichtenstein, JJ., concur NOT PUBLISHED PURSUANT TO C.A.R. 35(£) Announced November 10, 2010 fb)(5 );(b)(7)(C) John W. Suthers, Attorney General, Denver, Colorado, for Plaintiff-Appe�ee l(b)(6l;(b)(7J(C) Deputy I Colorado State Public Defen.derfLb_)<_5 );(-b)_Cl)lc=acio 80203 ·l \ �bpah.oe Dis:rict Court Eono:a::Je Carlos A. Sa..:!:l.o-..:r l Case Nun::..:.et 04.CR.1437 I r-B ?30?13 o? w3 STATE o? CC>Lo:a.ADo \ ?lai.:::!.ti.E-Appdee. I KA... Y-Y AR SA.i.\-1:NI I Defo:. t- ' b)(6) · (b)(7)(C) rub"".Llc D.ere:::ioet Col::,::ac.o . �tate � n. � . \ (b)(6);(b)(7)(C) Chief Au ellate Depu<::y I "i.290 Broadway, S-:ite b)(6);(b)(l)(C) Denve:::, Colorac..o 802C3 · i I er COL3..':' 'JSS O�!.,Y cr \ Case Nmr.'oer. · b)(6);(b)(7)(C) APPELLA..'NT'S �OTICE OF APPE..U I. DESCRIPTION O? NATER.E OF C�J\SEA.."'ID DIS?OSITION � TRL.AL COlJRT_ �ATURE OF CASE: Tais case is a crirn;:ial cie.£enda.:it's appeal of ::he 1:evoca.ti.o.r: of "'.:he de:er:rei j:Jdgment anc: sec.tence w.d/ or sente�ce whi::� was i::iposed by ci:e co:;r_ T.ce appeal is :ak.e:'.J. ?urs:ia....-it -::o C.A.R.. 3. CHARGES TO W-t::IC:E{ DEFEN""VA..l\.JT PLED: Possessio:i cf Co!ltro:Ued S·J.bsta.nce, ?ossession of Drug ?a.:apb.er.nah 2. DATE JUDGMEKT OF CONVICTiON :::.NTERED: }'.ill� 9, 2005 26 . l .. i . l . 2020-ICLl-00006 429 Sc:ied:..:.le Two DAT_ES SEt,7:'ENC:SS �OSill: SE�TE�CES: June 9, 200.S; M?..tc� 6, 2009 Two Y�s De:etted -;:.10�eo.t ''7;) 2:1c. Se::.te:::ice; �·elocv Co::.v:.cicn , P::i.tered, Proba::io::::1 T�=ind.ted L::isuccess:cl.v , ., Costs a::.d ?ees Co�verteci Judpe:o.'.: n:o a Ci-rJ Il. APP&s\L EO�TI Th.�O3.__\L.\.TIOK IF SO, .AMOuNI 02 30N7J: �/A IT:. ISS1..,�S ?ROPOSED TO :SE RAlSED 0� A??EAL :::ssues o:i. ap?eal may include, '.Ju� a::e not li.:x.ted to: T..:ie prop::ie-:y of :b.e revocation and/ or s ente::::i.ce, ±.e s:iffa::ie.r:.cy and accu.:a.cy o: -'½e 6:0CI12.-:ion on which e:.e revocatio:'.J. 2::1d/ o: s e.c.te::::.ce wa.s ba.sed, the consti.�ti.o:c.i.i:7 of fue �evoca.tio:l a:i.d/o::: se::i..tence, and any other issues Ap?cila.nt chooses to raise. N. TRA.i�SClcPT NFOR-V�TIO� A tra.cscript of all evidence take::i regardi.:J.g tie j_:J.dgo.�: of coi:viction anci sente::i..c:ug is :'.lecessa..._ry to resolve -.:he iss·.1es on 2.ppeal and :ia s. Tne court re orte:::s a.re: (b)(6);(b)(7)(C) V. ATIOR.."-."EY NFOR...\lf.A1�0� Defe:1dar:.t-AD � (b)(6);(b)(7)(C) o or2.do Su.:'.:e ?ublic Def 1" )(C) ;(b)(7 (b)(6) . � l .. ' 0 B ro2.c.w4y, ..,rue 129 t L-----� De:::i.ver Colorado (b)(6);(b)(7)(C) ":.:. .. . 0203 27 2020-ICLl-00006 430 w� exceed twe::i".:J-fi.Ve ., . VT .,.'\?PE�""DICES TO Tf--: , S �OT.::CE OF APPEAL. · A':'"..a::hed to ti:.is Notice of Ap?e2 ate co?ies of-i...e :o!low6g. 1. 2. 3. 4 ¼ci:n'..:S D�sigaa.ti.04 of Recore. 3..�vocation Order ?:.nc.ings of be trial coCT:t b)(6};(b)(7)(C} o_o:a.do State P'..l:::>lic De:e::ider (b )(6};(b)(7)(C} ppe, lla.te D e?u�, J::._.,,..,-::=--, S · b}(6);(b}(7}(C) 1290 B ::oacw2y) ur: ,L--,,---- -De:r:.ver, Colorado 80203 (b)(6};(b}(7)(C) CERTIFICATE OF SERVICE I ce�-4 that a copy cf t.his �otice of Appeal witl:. a�fr7"'•e�ts was serveci by delivery o�- tte Dist:ict Cou..-:, ::i.e 05.ce of t!J.e Dist:ict A-::toroey, and 6e Office ' -, x a<.: 6.e of the A'.:totney General (by placing the sane :2 die At.to (bl(6);(bl(7l(Cl Colorado Court of Ap?ea2s).. cw c__;f�c)lm .I I 28 2020-ICU-00006 431 ·.· ' ,;. . :••, .. .•J : . ; l :_ ', ••• . :,·-:. . . ·. - . . ':- / \ •·_. ·,,,i-•.� K.1.J.J:!J1..•·d.LUIJ'1:..;¥ll½-.!.-\� .• 1-1. .,l0.\�"j:,«! ';r1• · - ':" O!S-:-RIC:T cou.::r;-, ARAPA�OE COU�TY, COLO�AJO Co�rt Add;::!SS: P!"lo7e 'I! :.ir:ioe�: Arapa,oe Cou,7:y Jus-:i�e Ce.7ter 7 3 25 S Poto:ciac S:. 01 � 2 Cente:inia; b)(6);(b)(7)(C} . cou;:n USE ONL y . 2004CR001437 The Peo;:ile of Colorado vs SAMIMI; KAMYAR SENTENt.;E ORDER Defendant: SAM:MI, KAW .YA?. Date of Birth: 07/03/ 1 953 Count -Class Plea 1 18-18-405(i),(2.3)(a)(I: - Controlied s:.Jbs�-Pos.=,ess sci 2 r6 ?iea of Guilty 2 18-15-428( 7) - :J:-ug Parapher.,aiia-P::issess ?02 Plea of 3·,.;i;ty ASSESSED FIN�s & cos s ·Count# 1 ::>eferreci Se:,te:,ce H::VOKEJ: 2 Yea�s A1cohol Eva' :::ee 'commu:,ity Se-vice: 64 Hou:-s .:,eq:.iest for Tir.-ie to ?ay Court Costs • T, rv., CR VAS"'; r.iir. for of7 a�er 5/1103 Victim Sor,pensatior. Fu;id 0:fender identifica:io:1 Fund Count# 2 Court Costs - -:-, rv., CR TOTAL: Finding G:.ii'.:y Guilty $'.81.00 $25.00 $35.0G $'.52.50 $125.00 $128.00 $100.00 $756.50 Other Conditions of Sentence: FELONY CONVIC,18,r-..: ENTERS. PROB.0.--:-181\-- IS T::RMINATED UNSUCCSSSFU:..!... Y. NC FuRT�Eq JAi!.. iMPOS!::J. COSTS At\'D F::::S CO!\'V::.•r: i:D TC CIV!L JJDSM=NT. CASE IS C'--0S!:DJDS SAMOUR, CAR!...OS A agrstrate 03/06/2009 ate SAMIMI, KAMYAH Derendant 03/06/2009 Date ························�··········4•··········•+••·�-�·-���o�c� 5 •·······#••a••······· co!lowi.1;i this �ea,in� yoi.i are to oresent tnis fo:-rr t::i the Clerk· s O:fo:e for pay:11e�:. ?aymer.: is d:..ie by the e:--.c of !Jusiness 0.1 your c::iu:-t Da':e. Faiiu-e �o _::iay when d:.ie will res:.11: in additio.1a! cos:s p:.irs·Jar.: to HB.1198. 29 2020--ICLl-00006 432 I DISTRICT COURT, ARAPAHOE COlT!'-.'TY, COLORADO ! \ 7325 South Potomac S'.:reet, Centennial, Colorado 801i2 Filed in J.'le Div. I Plaintiff(s): TI-IE ?EOPLE OF THE STAIE OF COLORADO, u� . j -�:"l!).fi •r-Lrt., ),;U,;, •·� krv."'-Y A:f2- ')AQ � _f'\-t I C 1-------------------- ----------- l.ls Distri�t fourt Ara��hn C3tir.ty, C4lll. \ Defendant(s): A COURT USE ONLY .A. I Case No.: � CR 1 I Div.: ·1, I JUDGMENT I L.e:i H?l- · ·This Matter comes before the Court for er:try of judgment upon De request of tbe �ar1ies, and the Court being advised in the premises hereby e:ite:::-s judgment tor Toe Peo;ile of the State of Colorado ---------------------------- l{ � ,'4 A--IL and against the Defendant �.M. � for the mpaid financial obligation remain.ir.g in this case fron the Court's previous orders, in the princi;ial ano'.lll.t of$ _r_..· L"--o·_,£",,__G _______ -'tC;..-..... · Post-judgme:it interest shall accrue as provided by law. Done this BY THECOURT: I ,1 Judge Ce::tifi�ate: �opies of the �ve o:der 1b)[OJ;(bJ(7)(C) or paroes this ?5/ /0 1 . by r.o HANSEN BROS. PRll'ITING • L'Tl'..fTON, :::'.)LOAAl)O Im_. ,.el of record- . h, L--------- -;--:-�-:--'.......... 30 2020-ICLl-00006 433 ·.3 / 1l"!:D: !l0:>32C04CRC :i;.,u 7- :io;i � 52 o:s-:-.=i1cT SOU!n, At:{APAHOE CO:.JI\TY, ::.:o:..0R�DO Cou.---: Address: P'.")O:'"le �u:r.::>er: A�apahoe Coun:y Just;ce Center 7325 S Potorrac S: Ce7:e:inia ,,... 0: 12 b)(6);(b)(7)(C ) • COURT USE ONLY Case N·.JM:>er: The People of Colorado vs SAM!Ml, KAMYAR 204 $EN1ENCE OR DateofBirth: 01/03/1953 Defendant: SAMIMI, KAMYAR Count Class Plea F6 Plea of Gui':y � 18-i8-405(1),(2.3J:a)(ll - Co:-1t,oli- ed su::ist-?ossess sch 2 2 1 8-1 8�42 8t 1) - Jr•.Jg Paraphernalia-?cssess ?C2 Plea o� G�:ity ASSESSffiRNES & COST Count# 1 Deferred Sente:1ce R::VOKED: 2 Years A,coho: Eval Fee C::i":",'Tl:.mity Se:vice: 64 Hours Reques: :o: Ti:--.e t::i Pay C::i:.rrt Ccs:s - T, M, CR VAST r.,in for off afte: 5/i /'J3 Vi:tim Corn pensation "'und �ffe;ider identifica:ion F:ind Co:.int # 2 Court Costs - :, M, c.� TOTAL Finding Guil;y G:.:'l:y $181 .O'J $25 .OC $35.00 $152.50 $i 25.00 $128.00 $100.00 $756.50 Other Conditions of Sentence: FELONY C01\'VIC"7"10N ::NTrnS. PR.03A-;or-..: IS TERMINAT::J �NS�CCESSFUL:..Y. 1\0 FU�.THER JAiL JIVl?OS:::D. COSTS AND Fi:::.S CONVEiil'!:C TC c:VI!. ,.;;;JGMEr'{i' CASi: ,'S C'...CS!:D./DB SAMOUR, CAR'...0S Judge7Mag,strate � 03/06/2003 Date 03/06/2009 Date SAMIMi, KArV:YAn Defendant ••••••i•�••••••••••••••••••••••••••••+•••••*•••••••••••••••N6TICE*••••••••�•••••••*•••• F:::iil:::iwing t.'lis .-ieari.,g yo:.; are to o;ese.,: this forrr. :o :he C:eri<'s Office fo; ,oayne:-:t. ?ay::ie:-'.� is ciue by the e1od of !:>usiness or. your Court !)ate. Failure to ;Jay w'ie,1 dL.·e wil! resc1:t :n additio.~,al costs ;:,.1;sLar., tc ii811S8. 31 . lllL. l -· ,020-ICLl-00006 434 l. ! D County Co:.i.i :.8l :'.listricl C::i:.ii I Arapahoe Cou:-ity, State o� Coio�ado Coc1rt Address: 7325 S Potomac St., Cen'.en:i:al, CO 88�1\2 \ I TH:: ?EO?L!::: OF TH:: s I ATE OF COLOR.A.JO I \ l , V. I I Samimi, Kamyar 1,J�e�IB�n�d�a�n�:·�-=-----��-----------1 I, I Attorney or Par:y W1t+-iout A':to:,iey: (Na:ne & ,!l,ddress) ?hone Number: FAX N:.imber: I I · ,+. COURT USE ONLy .+. 1------- Atty. Reg. #: 1. Case Nurc,oer: 04CR1437 I Se:-ilencing :Jiv: 207 Return :Jiv: 204 COMPLAINT FOR REVOCATION OF DEFERRED JUDGMENT AND SENTENCE The CAI Case Manager informs the court that on J:.me . 9, 2005, Judge Vincent Ren aid a White placed the defendant on Deferred Judg,11ert and Sentence for 24 :nonths, following :he defendant's plea of guilty to Count 1: Contro:led Subst-Possess sch 2-1g/less (F6). On June 9, 2005, the defendant was transferred to Community Alternatives, '.nc. for supervision. The defendant's conditions of supervis·1on state: Count 1: 'The defenda nt will contact the Probaticn officer at those times and pla�s specified, and respond to afl reasonable inquiries." The defendant failed to appear tor schedu:ed appointments at Community Alternatives Inc. on July 19, 2005, August 15, 2005, October 31, 2005, March 2, 2006, October 26, 2006, Nove,oiber 15, 2006, March 14, 2007, and April 12, 2007. Attempts to contact '.he defendant th:-ough correspondence and telephone have proven unsuccessful. As of Ap�il 13, 2007, the defendant's whe.�eabouts are unknown. Count 2: uThe defendant will pay the victim's compensation fund, victim's assistance fund, restitutior., fees, costs, surcharges, and fines in the amounts and manner ordered by t�e court. The defendant will maintain lawful empl:Jyment with earnings sufficient to pay the amounts ordered by the court, and not terminate that employment without the consent of the Probation officer." ,,�, (. r� .,. \ On June 9, 2005, the defendant a:::knowledged receipt of an Order for Payme.of:.=:.J requiring the defendant to pay $1,245.50 to the Clerk of the District Court at the rate of $60.00 per month beginning July 20, 2005, and at regular monthly intervals thereafter, 32 2020-ICLl-00006 435 1. Samimi, Karnyar Case 04CR1437 Page 2 with final payme;i_t due 0:1 or before April 20, 2007. 0:, Se;:>tember 20, 2005, Judge Vincen� Renalda White ordered $1,200.00 of the su�ervision fees to be ;Jaid to Community Alternatives, Inc. As of April 13, 2007, the defendant has paid $198.00 to the Clerk of the District Court and is in arrea:-s $984.50. The defendant has failed to pay supervtsion fees to Comr.,ur.ity Alternatives, Inc., and is in arrears $240.00. · Coun� 3: 'The defendant will obtain an evaluation, counseling or treatment for drug use, alcoh::>, use, or a mental condition as required by the court or the Probation officer. 1he defendant will immediately enter, attend o:- remain in a:1d successfully complete treatment as recommei7ded in a specified facility or program, and meet all financial obligations of that program." On November 22, 2005, the defe:1dant s:.Jccessful!y completed a drug and alcohol evalua�ion and immediately enrolled in Cognitive Therapy and Relapse Prevention classes at Genesis Counseling. Information received from Genesis Counseling refiects the defendant was discharged non-compliant on December 15, 2006, due to attendance. The defendant had compieted 1/16 weeks of Cognitive Therapy and 7/16 weeks of Relapse Prevention before the discharge. As of Apr-ii 13, 2007, Community Alternatives, Inc., has received no verification that the defendant completed Cognitive Thera;:iy and Relapse Prevention as ordered. Count4: "You will complete 64 hours of community service." As of February 8,2007, Arapahoe Coun:y Judicial Services repo;ts verification has bee:, received to indicate the defendar.1 completed 9.15 of 64 hours orde:-ed by the court. The CA! Case Manager believes that :he defendant has.violated the conditions of supervision and requests that the court set the matter for hearing. Res ectfull submitted (b)(6);(b)(7)(C) b)(6);(b)(7)(C) 0, Centenm.2.l, CO, 80112 Phone: (720) 874-P,><6);(b)(7)(C) I Attv. Re . #: 14948 COURT l:SE ON""LY Case Number: 04CR01437 Division/Ctrm: 207 STIPL'LATION FOR DEFERRED JUDGMENT A_"l\""D SE1'"TI:NCE IT IS HEREBY STIPULATED and agreed between the People of the State of Colorado, acting through fie District Attorney of fue Eighteenth Jucicial District, 2nd fae Defendant, K.A..lv.CYAR SA..MIMI, acti::ig in person and by his attorney, as follows: 1. l.;n.der auno:ity of Section 16-7-403, C.R.S., tb.e Distict Attorney a;id fue Defendant have engaged in plea discussion, pu:sua:it to Section 16-7-301, C.R.S., a:idhave considered the previous recorc. of the Dcfenda.n:, the Defe:idant's education and employ:nent, the De:en.d.ant's attitude and potential for rehabilitation, and the facts a:id circumstances s-.1:::mmding the cri.-o.:nal c::iarges filed agains: the Defendant in tms case. 2. The Defend.a.."1.: acknowledges tt.at he has p:revio'.lsly bee:i ac.vised. by the Coi"t a.:id ':hat he u:iderstands, the fo::Iowi:J.g: �ature and elements ofthe ciarges aga:nst him, his righ: to remain silent and to decline to answer any questions anc! the fact t::iat any sta:ement made by him can be used against him, his right to a trial by ju..-y a:id the co::istitutio:ial r:gh:s incident� thereto, bis right to an attorney cUid the fact that ifhe is fina:i:ially mable to em.?loy an atto:ney the Co'.l:"t will a?:;:i o6.t a::1 a:tomey for b. at no co� to }nn:., the Defe::idant rep::-ese:it that upon ac:ep�an:e by the Court of the Defendant's plea of gu:lty, fue end.s of substa:itial justice wiil oe best served if t:i.e entry of a judgme:::it o: conviction OD. the Defendant's plea of gcilty is deferred, fa:: a :;:>e:iod of T�iO YEA.RS from the date of the ent:y of the j:>lea of guilt y.· Duri.ng such ti:ne, the Court □ay place the Defo::ida.nt u::ider the supervision of the Probation De;;,a..-tment under the follow..ng concitions: 3. Tne undersigned Disbct Attorney and (a) The Defenda:it -wit not commit another offense dur.ng foe period o: supervisio::i. . 41 2020-ICLl-00006 444 (b) The Defenda::1.t will establish a :-esidence of record a:id ::eside at '::::lat residence anC. not move :f:-o□ that residence w:itbm.:.t tbe consent of'.:ne ;cobation o::fice::. Toe .0efend..arJ 'will not leave :be State of Colorado v.i.thout v\:::itten perrniss10r:: from ::-ie probation o:5.cer. (c) T'ne Defendant vri.:..r contact the probation officer at those "'2oes and places S?eci.5ed by the proba:ion officer andiespond to all reaso:c.able Ulep.:rries by the p::obatio::i office::_ ( d) The Defendant will pay the crime vic'im co:opensatior.. :fnd, ::erituti.on., fees, co:1:s, and .fines TI fue amounts and r::ianner ordered by the Court. Tne Defendant v;rill maintain lavdill employoent wi:h 6e eamings su£5cient to pay the amoun':s orde:::-ed by the Court and not terminate t.::1at employment wi6out D.e consent of the p::obati.on office::. (e) The Defendant v.ill not use alcohol to excess and vrill not me any narco:ic, dangerous, or abusable d..7lg w:itbout penmssion t-o::::o the Court. The Defendant will not possess a fuear:rn, destmctive device, or otb.er darcgerous weapon ffi-'-..ho'.rt vnitten ;:ievnissioL from the Court. (f) Toe Defondan-': 'Wi2l obtain co10Se0ig or treatment fo:: drug abuse, alco:l.ol abuse, or a mental condition and will ren.ain m. a speci..5ed facility if necessary fo:: that purpose, as required by the Cou..7 or the probati::m of5cer. (g) The Defendant -...vill complyv.ri:h any other coaditions req-:n:red by tbe Court or the p::obation officer which are reas::ma.bly related to the Defenda:J..':'s re:l.2.b:lita:ion and :he purposes of �per-vision. (h) The Defendarrt V'ill CDID?lywi:b.. tbe foilo��g adciti.oncl co::idition.s oE supervis10::1: 1. DngandAlcohol Evaluaton and Treatment 2. 64---Hours Usefai Pu�lic Service 3. Payment ofCrn.rrt Costs 4. The District Atto:ney fu..'""ther ag:-ees that if the DefenC.ant satis:"actorily cm:n.piies with the conditions upon whicli the entry o(,udgment o: convic'ion is defe::-ed a:J.d fie impositio::1 of sen':ence is deferred and sa'isfacto::y complia:1ce by the Defend.ant wi:h the te::=ns of p:robatior.. is silown tbe::i, u�on the expi:-atio:::1 bf TWO YEARS from :he e:crtry ofthe Defe::idanfs guity plea, the Dii:rict Attorney will consent to :he entry by the Court of m o::der allowing the Defendant to withdraw his previously entered. plea of guilty; and, iftb.e Court so allows the withdrnwa.l of the 42 2020-ICLl-00006 445 ,I .I . guilty :;,�ea, the Dis:rict Attorney v.ri.J. thereupon oove for 6s:rissal wi'.:h prepdice of De crirnLlal case in which this sti-;i ulatio� is ::leC-. 5. Toe Defendant acknowledges that he ::J.ereby consents �o the �'.1...7.sdiction of '.:he Cmrt over bis :;,erso::i for a ::,eriod of TWO YEARS from 'die e::itry of his g.iil.typleas. T.1e Defendant further acknowledges tha.t by volunta..--ily andkno--wingly entering a ;ilea of Gu:1ty to the cr-.:::nini. offense of POSSESS!O:'i OF A CONTROLLED SLl3ST.'--'ICE-SCHEDULE Il-1 GR.-'._'11 OR LESS, F6, COLNT 01'."""E he thereby irrevocably waives his :ci.gb.t to a trial by jll.L·--y or by the Court on the cri::r:ri.Tial c2:iarges pending against :.iin::. in this case. The Defend.mt far.her acknowledges 6at by vobntaiJy and boWillgly entering a plea of guilty to the cri:n.i::ial charge of POSSESSIOX OF A COi\TROLLED SUBSTANCE-SCHEDULE Il-1 GRA_'\1 OR LESS, F6, CO�'T Or\'"E he tb.e::-ebywaives aoy constitutional, statutory, or o:her right he might otb.ervn.se have to a final disposition of this case a'.: 2L earlier ti::i.e than that ;xovided. for :Jy tris stipulation. 6. By agreeing to tbis sti:::,ulatior:.., fue Defendant agrees to waive all rights to a speedy trial, as provided in Section 18-1-405, C.R.S 7. In the event th.at the Defend.ant breaches any of the co::iditions regulating De conduct of the Defendant, fue Court shall enter JUdgr::ient and impose sentence upon such guilty plea. Vihether a b;each of condi°jon has occurred shai.l be dete:mined by the Court ·without a j--.:rry--.ipon applica:ior of the District Attorney or the Pro:Jatio::i Officer and upon notice ofheari::ig the.:-eon of not less than 5.ve Cays to the Defendant or his at'."omey ofreco::-d. The bu.:-den ofproof a':. sucb hearing shall be by a preponderance of tb.e eviCence and procedural safegaards req-cired in a revocati.o::i. ofpro:Jatio:i hearing shall apply. DATED this _5_ of _ J'_c_ _ev-f�_,, 20_&_:J _ �=- Defendant! _ / ,--')\J:lfr-ney for Defendan'. Registration Num,er / _ ,; Deputy istric� A"jo:ncy Regis':rati.011 Nu;nber c--;) I �,;t? 7 I/; JuC.ge 43 2020-ICLl-00006 446 DISTRlCT COl}RT ARAPAHOECOUl\1TY,COLORADO Co� Address: Arapahoe County Justice Cen:e::­ . 7325 S. Po:o□ac St .. Centem.ial. CO. 80112 Filed in th2- i),·,, JUN - 9 2005 THE PEOPLE OF TIIB STAIE O? COLOR.WO vs. Defendant(s): �istri�! C '.,�;; .lirapaiioe r:.�ijnty, Cu!,J. KA..'1YAR SA.MIMI Attorney: CAROL CHAMBERS, 18th Judicial District Attorney 7305 S. Potomac stlCb)C5);(b)(7)(C) tenteniaL CO, 80112 Phone: (720) 874-8500 Attv. Reo-. #: 14948 CO'CRT GSE O�LY Case �um�er: 04CR01437 Divisio:n/Ctrm: 207 COURT ORDER GRA-"'\.1l1NG PEI.lMISSION TO ADD ADDffiOi\AL CO�T(S) Lpon consid.e:-ati.on of the People's Y1oti.on To Add Additi.onai Cour:.t(s) to the filed Complaint md bfor:mation in the above captoned case, and the Cou.---t �eing fu.;.!y advised, the Court orde:-s tb.at the Dis:rict Attorney is giver: ;:,ermission to a.:nend the filed Co:::iplai::J.t and .Infon:J.ation in the above captioned case by ad.ding the following count(s): A COlliT TWO of POSSESSIO� OF DRUG PA.RAPHER....'-.IALLi\ Se:::tion 18-�8-428(1), C.R.S., a CLASS TWO :PETIT OFFEKSE Dated Y/ffor BY THE COURT: Judge 44 .J 2020-ICLl-00006 447 ' I ' \_ DISTRlCT COl,""RT ARAPAHOECOL1'"TY,COLORADO Cou..""i; Adcress: Arapanoe Couty Justice Ce:iter 7325 S. Potomac St.. Centenrial CO. 80112 Filed in the Div. JUt4 - 9 2005 THE PEOPLE OF THE STATE OF COLORADO vs. Distri:'. Coun Arapahoe Count)_. Colo. Defend.ant(s): KA."1YAR SAMI\11 A:tomey: CAROL CH.AMBERS. 18!1: Judicial District Attorney 7 7305 S. Potonac S:lle on �e �?'C_ Judge �� Judge 47 2020-ICLl-00006 450 :s. People v. KAMYAR SA...l\1D11 Jam.es J. Pete�, District Atbney for the E:ptee:i':h Judicial D�-tr:.ct, of tb.e Sta:e of Colorado, in :he-name and by :he au.t:tori:y of ::ie People cf '::le State of Colo::-ado, in:o:ms '.:ie court of the following c.Eenses cor::n:itted, or triable, in'.:..\� co1:::.ty of Arapa.:ioe. COL'NT 1: POSSESSIO� OF A COTIROLLED SUBST.4-.�CE - SCHEDl."'LE IT - 1 GRA.l\1 OR LESS (F6) On Feb�a.-y 08, 2004, K.A..\1YAR S�A_.__\CIMJ �av.rfu.:2y, :elonio"t;Bly, anc. knowingly possessed. one g:-am or i.ess of a naterial, conpot:nd, :::.c..ixn=e, a:- prcparatio:i that co::itained cocai::ie co�a leaves, a s�hedule Il controlled substa::Jcc; in violabo::1 of sectio:i. 18-18-405(1),(2.3)(a)(I), C.�S. All offenses against the peace and dignity oft.he ?eople of 'be State of Colorado. Jam.es J. Peters Dis'.rict Attornev b)(6);(b)(7)(C) l 48 2020-ICLl-00006 451 -I - I \ People v. KA.\iYA.R SA.."l\1IMI I, f J(6_l; cb_JC7 Jc_c i sa : .__b_ _ _ _ ___ :,ein.g d".l2y .TIVom t:.?or:. oafr. ys Tha: the fac::s stated in '::le foregoing fe!:my :;oo.?laint/ i:ifo:nation, here:o a:tached are +.:rue and :hat ::ie offe:ises therein charged were com�;:ted of this aE.a::i.t\, ow::i p�sonal knowlec.ge. Aur��..12:,4 s-.1bscribed a:1d sworn to be:ore me in l,�, A:-ap ahoe Com, , Colorado. b)(6);(b )(7)(C) Dated.: ,:-,--a.?-,:2f xp;.:at.ion ate: 1';?-.i.5-.,:;zoo,r District Attorney's Office Eighteenth Judicial Dis-.:ci.ct 49 2020-ICLl-00006 452 People v. KAMYAR SA..\ffi11 O??ICE O? TEE DISTI:UCT AITORl\"EY E:GHTEENTE JCDICIAL DISTRICT STA'i'E OF co:::.,oRJ\DO NOTICE TO: THE DE�A.c"\"T A..'ND BlS/HERATTOR.'\""EY I!\ 1::IB ACTIO� COi\IBS �OW, JA.\IBS J. PETERS, Dist:ict Attorney in and for 6.e Eig;i:eentb. Judicial District and County of Arapahoe, State of Colorado, a:i.d no::.fies �e Court and tb.e defenc.a:it that witl±l the time ;ieriods ?rovided in Rcle 16 of the Colorado R1:J.es ofCrim:nal Procedure all :naterial req_ui:-ed. to be disclosed by? art I of Rule 16 of 1=!.e Colorado ::lules of Cri_mina.:, P:ocedure will be made ava:J.able by c::mtacfug 11.e Office of the 01.stict Atto:n.ey d'.lr.ng normal business hours. A21 discovery :-equests may 1::>e r::iade in pe::-son at 7305 S. Potom;c Street, b)(5);(b)(?)(C) en:e:mial be�een the hours of 8:00 a.m. to 5:00 p.m. Discove..-ywill be provided i.:nr:1ediately upo::. request . J .I . 51 2020-ICLl-00006 453 People v. KAMYAR SA_,ffi1J Defendant Information Address: 3540 :.1:ALLA..1'JJ DR City: LITcLETOK State: CO Zip: 80126 A.KA: Birthplace: DOB: Driver Lie.#: Cl/03/1953 � Eye: .35-0 Gender: M..� Hair: BLK Height: 0509 Home Phone#: (303)346-8689 Race: W Soc. Security#: Tattoo: Weight: 0160 Work Ph.one#: Case Information A~ ~---,.,;;ency �C ase �­ 046942 Arrest#: Arresting Ageney: Date of Arrest: ACRORA POLICE DEPA.RTMENT / / BAC: CCIC#: NCIC#: SID#: 52 2020-ICLl-00006 454 I. D."FORMATIO� SLIP FOR CASE FILlli"G RequestWAR..�'T Request SUMMO�S :a.�uest SC'lvf.\10N"S (Sher.:f� Serve) (S:i.er'.n to S e:-v::) (By !✓-.a:i) SA.Mn1I, La.st Kamyar Fi.--s: (Ko:Je m.:,wn) A...U's: ADDRESS: CTI': 04CR1437 ?ione N".ll:l::,�: !(b)(6);(b)(7)(C) 3640 Ma!.:a:-d D:ive Lrdeton, CO 80125 PRES3NT I-OCATIO!\ OF DEFE:N!>AL'..Y: (As of Case El.i;ig_) Sa:ne DOB: 01/03/53 EYES: Brown RACE: Caucas:.a..7. HAIR: Bla�k SEX: Male BUILD: E3IGh'T: 5'9" �O"t;(.� MEDIC& PROBLEMS: (Kone lis�) CO. Dili\'cR'S LICENSE 1 j SOC.AL S3CL"TIIY � VEHICLE Il'>1'FOR.M:A.TIOK: None listed OCCl,"PATIOK: Ca: salesman EMPLO'YME'-,'T Il\rO: Onlµ:uted Motors and 3rokerage, 2171 S. Trento::i Way #226, De-ever, CO 80231, Phone l(b)( 6); (b)(7)(C) I DISTWGu-:S�G MARXS/TATIOOS!ETC: (None iisted) GA....�G A-;:.pn__IATION, I? A...�-Y: None kncwn. HIGH RISK ARREST: LIST A.}{Y EMER )(6);(b)(7)(C) KNUWN TO POSSESS "WEAPON: NO NO CY NO i.!NCATIOKS. :KEXT OF Kr-;<: -�--,-,,=.,..--, 3540 .Millard Drive, �ittbton, CO 88 l2S, fbl(B);(b)(7)(C) L--------' SCHOOL AIT.:'....r--.1)� IF .:l}VEl\TI..E: . _.,JI.�::qu•sting wa=t,.or if r:asc filing.turns i:ito warran� any addi::bnaknfuc::iatim: tba: may a.s!".s� Anpa:ioe Sbde'·• o:li:e· Fugi.tivc:/Wa=ts D::puty ir.. a::f:ztiug arrest Pii0-:'0 ..A..VAil..ABLE AT YOL"B. DEPi\...."R.T:.vfE�-=:': YES CER: fuv i::N""VES7IGA'Q\G OFFI b)(B);(b)(7)(C) REQU5S'I TO B.:: �OTIFI5D OF ARREST: ATTACHED: AGENCY: !'i'O AL'RORA PO:.JCE :OE.PT_ U-.v �sl'IGATOR P3:ON""E: fb)(B);(b)(7)(C) YES f' NO AC520 53 2020-ICLl-00006 455 Z I Certificate ofService I hereby certify that, on �ovember 21, 2017, I served true copies ofthis DEPARTMEt .;T OF HOMELA�--0 SECUR1TY EVIDD,TCE SG13MISS1O� and any attached pages by placing them in the out-going mail bin for delivery to the respondent at the following address: 1 KamyarSamimi DHS/GEO 3130 N. Oakland Street Aurora, CO 80010 b)(6);(b)(7) (C ) 1e CoW1sel . ll.1. \ _.. 2020-ICI 1-0000 6 456 \ ( (_El ( ?_) Event No J b_) ______. L subject ID: 359887663 NOTICE Name: DEPARTMENT OF HOMELAND SECURITY FINS #: 1238805650 OF RIGHTS AND REQUEST FOR DISPOSITION DMYAR SAMIMI File No: 022 732 918 NOTICE OF RIGHTS AND AOVISALS You have been arrested because immigration officers believe that you are illegally in the United States. You have the right to a hearing before the Immigration Court to determine whether you may remain in the United States. If you request a hearing before a judge in Immigration Court, you may be detained, or you may be eligible to be released from detention, either with or without payment of bond. You have the right to contact an attorney or other legal representative to represent you at your hearings, or to answer any questions regarding your legal rights in the United States. The officer who gave you this notice will provide you with a list of legal organizations that may represent you for free or for a small fee. You have the right to communicate with the consular or diplomatic officers from your country. You may use a telephone to call a lawyer, other legal representative, or consular officer at any time prior to your departure from the United States. In the alternative, you may request to return to your country as soon as possible, without a hearing. If you choose to return to your country, you may lose the opportunity to apply for certain immigration benefits or forms of relief from removal that are only available to people present within the United States. If you choose to retu.m to your country, you may change your mind and instead request a hearing before a judge in Immigration Court at any time before your departure from the United States. You should let an immigration officer know immediately if you change your mind. If you have been in the United States without legal status for one year or more and choose to return to your country, you will be unable to legally return to the United States for ten years, unless you obtain a waiver. ff you have been in the United States without legal status for more than 1 BO days but for less than one year and choose to return to your country, you will be unable to legally return to the United States for three years, unless you obtain a waiver. You may apply for a waiver only if you have a spouse or parent who is a U.S. citizen or lawful permanent resident. REQUEST FOR DISPOSITION I request a hearing before the Immigration Court to determine whether I may remain in the United States. \-< · S Initials ---Initials I believe I face harm if I return to my country. My case will be referred to the Immigration Court for a hearing. I admit that I am illegally in the United States, and I do not believe that I face harm if I return to my country. I give up my right to a hearing before the Immigration Court. I wish to return to my country as soon as arrangements can be made to effect my departure. I understand that I may be held in detention until my departure / --:, /Ar JI- /7�t?: fi...J"" Signature of Subject Date CERTIFICATION OF SERVICE Q Notice read by subject. otice � read to subject br � Kb)(6);(b)(7)(C) � �- (b )(6);(b )(7)(C) )(6);(b)(7)(C) L. I - , in the English Name of Interpreter (Print) ,-- language. --- November 17, 2017 12:00 AM Date and Time of Service Page 1 of 1 DHS Form 1-826 (9/14) 2020-ICLl-00006 457 " Non Profit Organization •• Referral Service u• Private Attorney list of Pro Bono Legal Service Providers UpdatedJanuary2017 http://www.justice .gov/eoir/list·Pro·bo no-legal·service•providers Aurora Immigration Court catholic Charities* Catholic Immigration Services Catholic Charities* 4045 Pecos Street 2500 1st Ave., Bldg. CB Denver, CO 80211 Greeley, CO 80631 3 (97�0 ) 35'-'3-6�4 3=30 3) 742-4971 �--------�( f-' � ,_-', � "' � Catholic Charities* • May charge a nominal fee. 1004 Grand Ave. • Will represent aliens in asylum. No collect calls. Glenwood Springs, CO 81601 Rocky Mountain Immigrant Advocacy Network 384 ·:: 97 0 ) ;:_ 060 0(;:_ :c:,. ;:_.:..2 c;:::___________---j (RMAIN)' 3489 W. 72nd St, Suite 211 X Westminster, CO 80030 Tel: (303) 433-2812 Fax: (303) 344-32823 rmain.org • Individuals in immigration detention • Children's immigration matters Dh!cl•imr,r: AJ> required by 8 c.F.R. § 1003.61, the Kxooutive Offioo forlinmiy1rtion Review (EOIRJ, Offi.Cfl ofthe Director, O.ffi.Cfl of Lesa! Access Programs maintain• a list of orp,.nl•ations and llttOl"lleys qualified under the regulations who proTide pro bono or free leGB,I services. The infomuttioo posted on this list is provided tc EOIR by the Providen. :EOUI. does oDt endorse any ofth11RO organJm­ t!oos or &ttorn11ys, AdditlooBily, EOIR does not participate in, nor is it re,ponsib!e for, tb11 representation deci•ioos or perfonn&nce of these oiganize.tioll5 or e:ttorneys, 2020·1CLl·0D006 458 .·"'-�� :-t,� . �yARTAf� b ft 0 "' :.. . D S IMMIGRATION & CUSTOMS ENFORCEMENT COVERSHEET RECORD OF PROCEEDINGS This is a permanent record of the 1mmigration and Customs Enforcement. Any part of this record that is removed ML'ST RE RETURNED after it has serYed its purpose. When the Record of Proceedings is removed from the file for use in any other proceedings, make duplicate copies of the record of Proceedings excepting restricted material and c\'idcncc: which is not feasible to reproduce by mechanical means. Substitute this duplicate for the original record on the inner left side of the file jacket I'iSTRt:CTIO'\"S I. Place a separate cover sheet on the top of each record proceeding. 2. Each Record of Proceeding is to be fastened on the inner left side of the file jacket in chronological order. 3_ Any person temporarily removing any part of this record must date and sign a notion to this effect; which is to be retained in this record, below this cc\ er sheet The signer is responsible for replacing the removed material as soon as it has served its purpose. Sec AM2170 for detailed instructions. 2020-ICLl-00006 459 NOTICE OF ENTRY OF APPEARANCE AS ATTORNEY OR REPRESENTATIVE DATE 02-13-92 D "-C.DAEJS Chai,; Applir-nblt lttmfs) btlaw·· I Dm o, m11,r"""l' o,� a "'•mbw In ;ood uandlng of rhe ltcr c,1 lh• Supr•m• C:c:11Hf af rh• ;J,,:,ed Stm•• .,, of, high•sl c:,Llr1 of the following State, lerrirory, insu/a- posussion, or Distdcl of Columbic ,. SUPREME COURI' OF c:; CDLll"I or a::lminiUrative a;i=cy ord.,.. r.uspr:r,ding, onj_ciinlng, restraining, di&bc,r-ring, or 11ther,.,,;1e ' �ulric1ing ,,.,., in prDC'licing lcr,.,. :?. I an ,;n occri:di1c-d roprt1Se!"l!C1fiv,· or rhe following nomnd religious, chcrilcible, i.ociol Jen,:c'I', or lill"lilcr or;oii.!..:Tion eucblishe� in the Uni1e.:I Sratu and which is J.Q r o,coi'"i:i:ed � )' the 3ocrd: I err,, 01 Soci ,:1 ad with ___________:__________________________________ , 1he �om� of recard who pr•viou■ly filed II notice al OQi:,•ara,c:e ,,, tl,is cau and m1 ct:i;:e�rcnc,r is et his reqvur. U/ .�•pp cht,-Ji: tMJ ittm, clso ,:ht ck itrm I 1,r !! u•.l,,cl;ri•"'r is aP1Jro1Jnr,l�.1 [] l., Orh...-s (E 1

.IX'.R..L'iS ,_ N A'-fE I Tn,c, i::r Ph.11.i.., M. f'1m ) 621 Seve.,teenth Street, SU� te 1555 een·.rer, co 80293 Tc.lB"l-0!'-.'E N1..'M9ER (303) 2')�-0707 :(1 te:ri'Tla11 ,.,.,,,..t.= AT::-0/tt,,'YZr Q,'! l'U/11/JU,A,/'IT T"O -:-HZ ,-,u-.,,.cr .o.CT Qr' ,,,4_ / HZ/11/ZllY C:.Ql'f:lr:.."T TtJ THZ ClfJC:.!.Cl:l:i/ttZ T"CI TMZ ,"'OLLQI01,-C:. /ttZP,J I COLOR OF HAI� COLOROF EYF.S__ __ 8�c K 6'rbw rJ __, I - ---- .J -- · · -· · fATHE w s NAME AT 71ME OF :rOJR ARHIVAL ··--••'" - I . l(b)(6);(b){7)(C) _ -- . -�\10THEWS MA70H, i-.A'-lr.. ------ i . . L ) b) ( (7 )(C) l,.,.b)(6 ; - ...,, ,- - -,- - --:-:-.....,-::---:-----:-:- -----<- 4 Flll IN THE IT EMS ,.'I �IS BLOCK AS TO LAST.A.RRIVAL 1"1 :.J.S, !Exr.l:,ae anr re-Rrlfry sher on a/J,enc� ,.,:,1,s, lh11r> si> � CBr>B-:I• or Mexico,) ...- i.·--months -· --- ·.-- --·- ---.·po1:n o,·A.�ifr;AL. ·--- · '.lATE orARR:VA · I NAME u.-JOER WHICH. ADM'TTED·--- -·--" · L - · ; ).J.R�'fAK. 'SJ;M//llt ' -- ----------�------- --· OF- --CONVEYAr-CE· NAME OF VESSE:.. AIFUNE' 011 on,E'l MEANS · I NA"1E or TRANSPORTATION �:.•P�r-.� ' ------ ------- 5 POR- OF proposed DEPA.q�L,RE _FROM UNITED STATES 8'>- Lu.r···n,AiJ.:5' � . _,t;/r l..1�- 1 . /' D"i,/E 01' propr:ised 0E"A<1 TURE J,.). 1FW�ZE:.. ·y, ! c;id.J(..\<\1<\ , LENG:"H or 1r,..•-E'-.DE.::: AB S.ENCE ABROAD G1vF NAME Of v�e� Yf"'...c\� - 6. FIL .. IN ITEV 6 ONl. Y IF YOU H,WE P'lEVIOU.S!.Y OBTANE:l A PERVl1" TD 'lEEN-:-ER :.ocATION OF iMMIGF!ATIO'I AND NA-:"LJRA.iZAT or-. O•FICE ISSL::'JG LAS. P[RM'" ISSUA'ICE DATE OF l.AST ?ER !City and Stars/ __________ I T ATTAChED. STATE HEASO'l -----,---- ----�'_ ·--- ___ . ·-·· ____ .. _ ··-· ··- .... --··. ··---· ---- ------------- - -- - ---· !Yj fl'\�\<":.\"" � . flOfL . -rJ.Je ----------- )Rl,I 1-131 (RfV. 4-1-84)Y _;Jtl - ! •• f,t,Y LAS T PERMIT � IS A.,.TAC-IED AT TACHED ------· __ _---=-! .'S 1-.'0T if i'EHM:T S A-;"TACHEO. S"!"A TE O:P,R ATI0/11 ::lA-;"E ______ j 7 · ,. · ,:_ · .. ''',N'3a �:•1,·:,, ... j•. -. //er ---$·:�e�.:' (;;tt,a� nJf'Loo. i��-)�4 \VE� o.� -\-o ··- ··--,- · EcF.�-; - T'IANS-:-;::- ", ;u,,· □ -t>A'ss.o ·11 w.� c; OVER .... ! - -·----·-· -·, - --·-· -----··-- --- ·--- --·------. --· _. - 2020-ICLl-00006 462 -· . l - . I - ! dlf'1� a7 01 -� □ � 10. I M'have not have •�lied rn bus!ne. ss or emr;,fcyment outside Ille Unltod States slr,c;e I became • pormaJ\ent resident ol Ille \Jnlb,d States. �f you have engagod lh-i,, briefly deset1be el\d sllow period& of suet, empl<>yment or bvsilleS& activity.] ., i. f ., 11. Slr,c;e I bec,,me • permanent re.sldent of the Unltr,d S!a!taS I have iQ".;;ave no!clefmed,nonresidentalien stalu� lorFeI';' for wMch yau c(d , oo! file a return lor !NI -ton.) D .( ,.. 12. I 13.1 14. Odo not .Intend lo return lo the United Slates after my temporary wisi! abrc:>ad•. Udo I ld"6o CHECK ONE: Odo not intend lo retain my status as a lawful permanent re&ldent. �Y Alien Registration Receipt Cardi� attached. D Application Form 1-90 for issuance ct Alien Registration Receipt Card is attached. 15. The Permit to Reenl&r and my Aijen Registration Receipt Card. ii I submitted or applied for that card. should be fo�arded to: �addresa es &he>Wn in block·f 1:on reve�se. 0 U.S. Embassy or Cor,su!ate at D U.S. Immigration and Naturalization Off"ice at D 0lhe r {Specify) 16. The applicant must sign this block. .... CERTIFICATION OF APPLICANT If application was ce>mpleted by other lhan the applicant !hat person must execute Item 17. J certify, under penalty of perjury under the laws of the United States of America t . . 1-7. Execute(j an (date) �C 6 �Q oreg => . � ;;;:::g:;: 'fl.9.,0. jgnature "--" .,,,. � 1 � . .....___ � .SIGNATURE OF PERSON PAEP.AAING FOAM, IF OTHER TH.AN APPLICANT I declare that this document was prepared by me at the request of the appfica.nt 11nd is based on all lnfonnation ot which I have any knowledge. (Address) (Sig nature) Action with regard to application for issuance of Permit to Reenter Action with regard to Alien Registration Receipt Card D 0 ti!.i TION 1-151 or 1-551 submitted by alien retUN111d « D AR-103 or AR-.3 submitted by alien returned __ New 1-551 Issued on basjs of 1·90 ---'"----"'..--, ,. Ir DISmlCT HOV Qf 11D ""' OEN I (Oate) APPLICANT - DO NOT WRlff BELOW THIS LINE �-- .... SERIAL NO. OF PERMIT ISSUED: If 4-gL/-7:; OF'FlCE·· [B)Oaz., DENIED (See deni•I nr,tir:e (Or �on(s), GRANTED Permit valid to 0 Slngle enl(Y II - Oi 9::L OlMuttll)le entri• DELIVERY OF PERMIT �VMAIL □ TO APPLICANT PERSON.-\U.Y (!v ) : .1.. I .- . 2020-ICLl-00006 463 4 INmALS OF EMPLOYEE EFFECTING �VERY l(b)(6);(b)(7)(C) OAI I I /IJ/;1q o : '. __. (b)(6);(b)(7)(C) L--....,.,.."'"' -------,,......... D ,p om,,re , F.A C. S 30 October 1990 Amer ic11n Ooard or Urology 750 POTOMAC, s UIT£ (b)(6);(b)(7)(C) AURORA, COLORADO 8>,,..,1,,_ 1 ---� TELEPHONE, 367-8500 A few years ago .L we1.,, ••• _. irvand 's doctor while she was vi.siting her son in the states. Her son approached me regarding his mother's recent condition. She had apparently had a stroke sometime last week. I rr..ade a few phone calls back to Iran concerning her condition. I was told by her doctor that she did indeed have a stroke and is in serious condition. I verified with the hospital that she is staying in, that her condition is serious. I woulci strongly reco=end that her son go and visit her, because at this point it is uncertain how much longe� his moo will be arou�d. Sincerely, r6);(b)(I)(CJ [b )(6);(b)(7)(C) Presbyte�ia� Hospital Aurora, Colorac.o .l . ' 2020-ICLl-00006 464 I .. _____ kb)(6);(b)(7)(C) Room r .__ \ \ 30 October 1990 TO WHOM.IT MAY CONCERN: 5 ( ( A few years ago I was j(b) ( );(b) ?) C) I doctor while she was visiting her son in the states. Her son approached me regarding his mother's recent condition. She had apparently.had a stroke sometime last week. I made a few phone.calls back to Iran concerning her condition. I was.told by her doctor that she did indeed have a stroke and is in serious condition. I verified with the hospital that she is staying-.in, that her condition is serious. I would strongly recommend that her son go and visit her, because at this point it is uncertain how much longer his mom will be around. Sincerely, r)(6);(b)(7)(C) yterian Hospital Room fb)(6 );(b)(?)(C) Aurora, Colorado ,, .i j i I .I 2020-ICLl-00006 465 �����-::;���-;,��;�� � - - � � -�'.� �-����-rs7.5_��-i•�-;;···�tT�;. - E' �U.E.T,»��,sA.,c,,;;,_-·--'-'--'---'"'.,...--.........-�...........'-'--'� � .�?�:.:=��t=:/E� n: •·. -c :tr<): i. .··.·"-· .·:-->':--,c,�-··. - ' ·.·::. . :; ' J' t ;} ,, I .,. __...,o,M.L.O� , ·- .. - .. •: . , . :-;,.. ·-�·000.'0......<.f(.f;jr��, l!".-�-i '�•�r�r\,�� . -:\'.4��.:�.;.,-ri,.,..,4·,:.��·i-"� .....\t:��_;.tJf;���.;�g�{1i;�f: 1 J T \,., ·� J' i ::, ➔ i t� ! � J 1••· ,j '���i•.:.:�.:...-:-_':1..;;,..�-·· :..-t;·,_:�_A..:,;;;.. ::.�tl· :.:.;;;J:'.L.,.:,::J�:++:�;;.i,u�-..;.:"-c,ii:;.i::w"' r.--.---'-'-· ,c:-;,..t:"'?-''[.::.. �;..�':-':·�:..;;·:':.:�: ��';·_.'f�;). -""...;.a.:=:,:_;;c=c.:,:.;=!=-"--'-,rc--==='""'� ,, . Ci()J ... , - ,)·•.(JF�; 31°667�02�i:2(). l i::?O ....: .:.:"" , .. N?,� ...,_f.So._ OA,��IU-. lh lH - -� --00:·�' -· f', (b)(6);(b)(7)(C) U.S. DUAlnM&'IIT Of . PETffiON FOR 1\ ,urna: 111(l11!GllATION AND SATlfllAUZATION Sll:R'1\. DUPUCATE (To accompany Petition Monthly Report on Form N-4) ,,, Court for t�T Sr:':RT, To the Honora.ble 44383 No. Qi;, A.R. No. CO- ,ORA:::)lf)---1E:ilVE3, 316 This petition for naturalization, hereby made and filed under section Immigration and Nationality Act, respectfully shows: . fURALIZATION CQr 03?\"0 (a) -------- Ka�yar Sa�i�i (I) :-.1y full, true, and COTTcct name ,s -----------------------------Kett 1 C . Aven :.le · (2) My present place of residence is ___ 15 91. E , t:Vu,nf>f!, at?d strt-el) fA/Jl. ·"'o,) (J} Jw3.5bornonJA�i:JA:S)' 3, 1Cl53 ,in (4) l request that my name be cha.ngecl to -�o (5) (6) ("?) (8i (9\ (10) (II) I,.:: t.tleton ·-----fOnon�-M-�-1----- Co2.oraftc:L!U)_l__2 2 ____ --··-is•,,a,; 'lip Code/ _____________ -:-�an ___________ ------ --- --- ---- --- --- �_£Janee _____________ I wa5 lawfully admiutd lo lhC United States !or pcrmill\cnt residcnct and have no: abandoned s·Jch residence. (I! petition flitrc or :ni, pctitior. anniN1 bq_in:iin1, J!Jnc 1�. Pl�. 1nd cr. ::ir,i !YI>" J. 19��. ,.. , :!u• !1\JJ. p('tiod l'Jciinni_nJ Fcbru .:n,- U, 1961, :i.-,d c.ndin,tt Oc,otM=,- :�. �97�. or r ,..:u. ti\(•:,,�•1t.c-d :.iftt"r fi"c �·ur, ,,f ,r-ni(C' 1vr.dcr �!it" .A.:-1 cir J\J:,.c .'0. lQ� rP.[ j9:". !b[ Con.grr.a). 1.r �pJ,f:l\c-d f,on-. �uch nr-.·ic�. l ,.,.,a,., s-c·o,:n:ucd Ul'\d.c-:- hon(')r."l�lr- rnndirions. .-..1 th .r lill".r- of c-nl !Hmc'l'H. trer.i"t1,c1r.r-n�. :,r 1niJlJc:ion l •·:n .r. 1 ;-,<" L:1ni:d SU,l<'S, :!'Ii: Ca�u: Zvr.<, .�rnC"1"i.;,1n S:amcJ.1. o, S"'-;i.in., h:and. If n.01 in ,1ny ,,r che\C i,:�C"C1.: "'-":t:\ 1l wf1,1II� ;idmiue.d co 1hc Uni�c-d St3ro f-, r ("C1m.a.ne.n•.1n::<.1�..:< ,,,'�)E�uc-�t io cnli.1,tmcr.• c: u,du1,'1�t'lr,. I -.:1,i nevc! ��u.:ni Crt1r:.' iuc:i-ii w-:vicc 011 X"C:)unl of ailen�t I •"U nol a ..:on'-!;ifflhflu1 "bjrc.or who �!ot1'\C� no rn:i::3:-�. ,i:- . or JU..-.:.....,__ --- • • :ar rdu,cc! ro •<-OH the uni(<'fffl. ( ha..,c not c,.rr,·1c-·.L.,�'f bttn �,:t!"JrJ1I z.t'd Of'I rhc b1S1J. of l�t ,-amt �,iod or �fVL�t.:. a pcric>d of at l�ut 10 �ca,< ,mmcdia:cly �rccedin� tht dac, of,�:­ l �IJ"JU.1.L:ltVi. .l,....-�-·- ·"� :m. rubsidiary. bunch. a!ftli:11� or subdivi�ion :!".c-reof. nur ha,.-c l 1cs p:oh;b:t ed b:,- such Acc. ic�cd 10 the pnnc:�ie) o! :he: Cons1it.J�:o:-, of the L':-:1tc-C Seate.� a11d mr ::::::ed ffu.:-;\. �10:::: he oa:h of rc:i1.mc:3(ion a:-.d a.ll�sii�c-= t'runitxc b)' t?lr en �c�·.:�nC:: b\· la.�·. : 1., bc.1r .-:1.rm� on -��al! c�·!.1.,c L'ri1i:-c .S1a.t�. [(.' of na.ticm:i: im;x,:'""',ancc undt:: .:i\.:::.a,. C11rcccor (Unlc�:,1: curr.ptcd rrirm) (h;a� J .know 1ht con�ents of :hil petition re, :"".il!ura:Lza�io:-. >c!ilion is signed �v m< with my foll. true name. So Help .'-I< God. AOMI�ISTERED BY DF.SlGNATED EXA.1\fISER 1d sworn to (affirmed) before me by above-named .,cuuoncr in the r�tivc forms of o.ath shown in said petition and affic!a,·it at OE�WJl;_R, -G�thi�� d.ay of 1h1s ______ d.ay of ,19 __ osfepE�. . ,'. \: .\;(,. ' · I �• &ir,,roud £.x�nillfrr. I HEREBY CERTIFY that the foregoing petition for naturalization was by petitioner named herein filed in the office of the clerk of said L coun at DENVER, COLORADO this . (b}{6},(b)(7){C�=onno_ · o-c [SEAL) 2020-1 1. Ll-00006 ztof 29tbay of _____.� PETITION FOR I\ fURALIZATION U.S. OUAlfnffNT OF IUST1C£ IMIIIJGJtATION AND NAnJllALIUTION !IT.IIV\ , ··•· DUPLICATE (To accompany Pet ition �o. __-44S a.3-________ Monthly Rcpon on Fonn :-1-4) To the Honorable lJ.S. D"."ST3TCT Court for tlrlTS':''.:' 1.iwrul ad:r.is.sion fo, pcrma�ent tC'$(Geni,.:r. and. J have been phy:sL..::al1y �rtsc n t i� the t.:nitend af1,r my lawful admission fo1 permanent residence. dunng aii o( "'h:ch p,-:i:x! :::y saiC 1 c:1 . o, or an A.m-e:-k:.a.n irutitution or research rccog niz� a.� su.:h hy 1 t-. r Anornq· Gtn�raJ, or 3n Amuk.an firm or corperanoo (ngaied :r. w�.olt or ;r. par. in :he Gc,:r:C\pmcm 1.."l f fordgn ::adt and commerc:t- o f th< t;nired S�3IC.."-, o r subsidiary thereof. o r of ,1 :,ubEc :n1rrnae ton� orp:3.mla� ion � n ..,hich. the Cn:r cd St3l� p:t:-� 1cir,a: t"i by uca.�y or su,tute. or is au��oriztd 10 p,e;fo rr.-, t�u: :-:i:nistcria.: or p:-itltly fun\'.: �{oni o! a r di;iou� denomino11ior. h.1h·��g a. bor.a fu:k organ,t..lticm v.·11hin ��-� Lnite:d S�a[e:5-, o:- is engaged .soi c:y as a missionary by a r�:ig:ous dcnominat:on or b� an imcrdc:nomina1:or,al mi��ion orga.riizarlcin ha.vi:-.,: a bor:a !"1 1'.!c o�gan:ta�,on �•it�:n �he Uni1c:j Stau::s, and s1.1ch spouse i.s. rcgula:ly s.�ationcd abroaC in such ernploymcrit. r in'.cnd i� good fa.i{h upon nacur�.12.a[lon w 1L\lc- abroad ""·lth my .,po1,,1,k' .ilnd to tc-:tiu�c my rt1ddc:nce withi:-. the United St;itc-� 1mmt"di::u tly u por. !crmi11.J.1ion o! s.uc� r:mpJoymcn� :1 b ro.ac!. (9) ( l! p,ctl1ion is (ilc::d under Sc-erion J:?8.) I .!'ta..,c :i.er"'·ed honor�t'iiy in !!'".c Armed Forc.n or the \..' :::red S1at� for a. ;:.,,criod O! ;,crioci au,cga.1:ng :!'::tt: fa�. I ha\c ;,cTc? lxc:: �:,uo11cd fror.1 :he Arr:-;ed For.;cs of !'!-,r United Staats l:nda \.'t �n:r !�an �0-:-,0:--41,�;c i.:nnd 1 t1<,m. Ir no1 still �n �rvu;c. m�- �� \·ke it•:--m,na.:cd w:thin �;.� mC1nrh� o f :r.c filin� or m)' petition. (10) e r r pc.rnion 1� filt'd J ' r'IOtt s«11or. '.'29. l Whi:< .:i.� :i.lic-n or r.o ndti1-cn nil! or.al of C?l C' ',.' :,;1N.I S< -1.•e1. I ,c:vtrj haH no1 bttn, within tht manin� of :ht lrr.:,iigra1>or. ar.nrH�h . .affil;.a.!c: or s·.,,1bd i...-i�lon :�.er�of. nor have l durir.i s:u..::h perioC belLc-vc-c! in, ad\·oc:a�c:d, e:-iga�cd in. or per(o rmc� l:".y �1 f the a.i:t:s {'f .:ictivitic-s p rohibi,ed by such Act. ( 1 2) I amt and have: be-en duriri p. a.1; 1t,c � :"iod\ :--c-q u1 rC'd b y )a�· . ::1 :,criton ,, : _g.oo<..1 moral 1.'.h.a.ra..:u:r, anad,c-d 10 �he- rr:�.,i r,le) a: 1hf' C"on�Li�'..!t ', t..1:--. o! lhc t.;�.itt'C Sc.lees and well dispc,$td 10 the good order and hap ;,ini:s• or lhc Llnitcd S:a:c,. h is n,>1 �nlcn&ion i :. i ood faith 10 become a ciriu:n of the lJnncC. Sl3lo and :akc "" i�ho�� qvalifk:t: ior. :he oa�� c,,( rcr.·.;nc1.1.,!0r: ar:.d 3ilt � J3n:c p re-scribe� ty :he lm�!gi-a:ion and Nat•'.4.>n:-. J�y Ac�. aJ'\� co tt!-1dc pc:rm-lner:�Jy rhc t.::�:t�d St:i.'.i:-,;. : am w:Uing, '-"'her. re"q\Jlrrd by J;iw, �o hear arms on bch�lf uf ��- c L'ticc-d Sta.to. tc.i perfor� noncorr:batan.t scr...-k� in [ht .i\rmc� Fo:.:-e� -:.,( [he � :-: : c c:-d S�ai,;�. and t o pc:fotm -.li r k or .,a!iorial impor�.ince undc� ci·• iliar. dirc-cwr (uni"� t:xc::n�ncC , �c-r-efrom) . (14) J am able ttJ ,cad, write . and speak 1hc Eni:li $h lang uage (ur.kss tltcrr.p1cd l hc,cfreo:'!l). and I ha.c a kno�·lcd it • and undc:.\:andin i of t h < runcamf !ht ' )istory , �d of :h'l: p rinci ples and fo,m ot go•cmmc::1 of the Uni;td State,. i\mcrka. l 5wear [:i (fi:m) that ! k.r.o w the cori.ttna er [his peti\1or. fvr natu ra:iz.a1ion (l �l Wherefore: J :-c G:UC"tt cha1 I may �c adm i!:c!'O a d:lze:1 of the l'nl�ed Stites of .. .s ubscribtd by me. and Lhat rhc same are cr-.,c ·. o the best of my kno"·lcdgc and belief . .,ad 1hac ch,.< pc'! ition is 1igncd b>· ,,,. witr, m>· foll. :rue name. 5o· Help �le God. (11) =� ( 16 ) --=<�� B�- �· WHEN OATH ADMINISTERED BY CLERK OR CLERJC OF COURT DEPUTY Subscribed and sworn to (affirmed) before me by above-named pe titioner in the rcspcctive forms of oath shown in said Jl(:tition and affida,· it, and filed by sa.id petitioner , in the office of the clerk of said covn at ___ ______ this ______ day of ________ ___ __ 19 ___ Drpu,_t Clcrt. ;SEAL) fOllM S-- (Jl[V. �J.n)N WHE� OATH AD�INISTERED BY DESIG:'i .t.TED EXAMl:'IIER Subscribei•td. Pe1iuoG.ND NATLIIALIZATION SERVICE FEE STAMP APPLICATION TO FILE PETITION FOR NATURALIZATION Miil or takt ,o: IMMIGRATION k','D NATURALIZATION SERVICE Q SEN (See INSTRUCTIONS. BE SURE YOU U!\'DERSTAND EACH QUESTION BEFORE YOU ANSWER. IT. PLEASE PRINT OR TYPE.) G-360 ALIEN REGISTRATION ·D Yes J!T No (If "Yes", explain fully) ..... •Jil nglishl. . . .... ,9-,0 ..,-,. R.�.,t-······· ····· ····· ····'� ({:;;_y·t········_Lcyf··.z. i ; manenr res,dep.ce was ?n.l.!....1.. 1"¼ D'"}J./Jl1 ... . _ .. . " "'i'J1 iLw.o.u. X-E-c't:.. (G..,) Jh..fl� .............9.. .............../...9. .. 7.9... in the Unm,d States since .. Yes ·· ji;;!Yes ·· � Yes D No .under du: name of :,._;L,::,.r_o.a.;f.,.IyU (Stare) ffci'"._, illi,, ····· ''"" iYS e...uJ€vY•b£ C{ . �,hi., ii ____;_i3•yl . . .. -,.......... M if't........\.!{. ········�················ f have been physically m the Cnued States for a rnra.l oF '" ,he Sra.D CoMPA.."JY, Bt:S COMPA..'IY, Oil OTHER ME ...NS L'SED TO RETL"JlN TO THE UNITED STATES (b) Since your lawful admission, have you been out of the Uniied Siates fot a period of 6 month! or longer?. .....•. DATE llETUll"1ED NAME OF Sl-lJP OR OF AIRLINE, R.All.110>.D COMPA..'!Y, BL"S CoMP>.."!Y, Oil OTHER MEANS USED TO REn/RN TO THE UNITED STATES (�) months. � No PLACE OR PORT OF ENTRY THROUGH, WHICH You RETL'RNED TO TBE UNITED S"t'.\n:5c If ··No·•, state ··None·•; If ··Ye5'', fill in following information for every absence of more than 6 month�. DATE DEPARTED cA .J 9 7? Yes If ··yes·· fill in the following information for every ab�nce of leu than 6 months, no matter how 5hort it was. DATE DEPARTED □ No ONo ····□ Yes Pl..>.CE OR PoRl· OF ENnlY THROL"GH WHICH You RETUU-,"ED YO Tl-IE UNll"ED STATl!S · ········-·--······· .... Form :-,;---100 (Rev. l-Hj) N (1) 2020-ICLl-00006 470 (OvER) IJNtrED STATES OEP.ARnffiNT OF JUSTICE l"lMIGllATION AND NATliRA.1-JZATION S!!RVJCJl 0MB NO. 1115---0009 Approval Exp,re, !/31/84 FEE STAMP APPLICATION TO FILE PETITION FOR NATURALIZATION li,fail Of cake to: IMMIGRATION AND NATIJR.Al.12.ATION SERVICE SEN ALIEN REGISTRATION ( See INSTRUCTIONS. BE SURE YOU UNDERST Ai.'\'D EACH QUESTION BEFORE YOU ANSWER IT. PLEASE PRJNT OR TYPE.) Q G-360 Section of I.aw ( Counn-y) -c (4) I request that my name be changed to.... c.c.. ..c ... --(5) Other names I have used are .. ( Include maidm name) K.i:\..m.i. ······ ..-. (6) Was your father or mother ever a United States citizen? . ... D Yes .aJ No (If "Yes··, �lain fully) (7) Can you read and w:rite Engfoh?. ............... ·Ji'J (8) Can you speak English? ... (9) Can you sign your name in English? J< El..11'l .y r,.R.... .... ... ....... . (11) (a) I have resided cominum.isly in the Un;ted States since .... J._ . ·Jil □ No □ No O No " "'i11iiw0ol..u K'l:"tc. :,..J:.sc___o.asJ.rU {h..t'.1� ............q.. ......... /.9. . 7. 9.. ........ ....... ...... .... :e.:4?:J.-e,.IA(I b.£..�, oft911 .C.OL.O..R..�Ci�:..J '�' s .,&..n') LtYL,· (IO) My lawful admission for permanent reside.nee was on.JD.B.�·······················'.j ... ............. (b) I have resided continuou1ly in the State of /9..£.9....... Yes ·� Yes Yes ..{Ci ty) (Day) .under the name of (Srate) s;nce .(.��.. ::.:_&,, ��;..,,.-, i.l..� Ll ..'fC....5............ (c) During the last five year-s I have been physically in the United States for a mral o/4!1. � ............. . (12) Do you intend m reside permanently in rhe United States? £Ill' Yes □ No If "No," explain: , . momhs. (13) In what places in rhe United States have you lived during the last 5 year-s? List present addres.s FIRST. ( llfl (a) ·Have you been out of the L'nited Stares sifice your lawful admission as a pcrmanem resident? If "Ycs" fill in the following information for every ·abscnc� of le!J tht1.n 6 monlhs, no matter how short it was. DATE DEPAJlTED DATE RETURNED KAME OF SHJP. Oil OF AIRLINE, RAILROAD CoMPAh-Y, Bus COMPANY, Oil QrHEll MEA,_,S USED TO RETU1lN l"O THI! U,_,!TED STATES Yes � No . ., Pl.ACE Oil Po>-a3) 1' 202CJ-1.:te.B., l�.Q . .:3: £�.b.u.ft.P.."';J:2J� O..V..�.Ll. � (c;) (d} Occu.PATION 0.. TVPl! I A!IDn·ss ( 33 ) Complete tlus block if you I am... 19gQ ave /».'j �.med. � J � 'Lu.o..Kc.e...si: ................. .....�. �l �.'..... The fim name of my husb �S.� mutiod. div.xON ISFOR -. SOCIAL SECUR:TY . BENEFITS. SHOW SOCIAL 1 SECURITY NUMBER: · _ !' MlODLE NAME - - _ _ _ _ _ _ _ _ _ ___ __________ ?LA CE O F B I RTH j .: j -----------�---------'----- ATA FOR IDENTIFICATION OFTHERECORO TO BE VERIFIED Kamyar 1· ! 4 H, / t,J,:;vj(L<:- , tJ� , lilutusL21 I 7s i _JI 1 _________________ _ J _____________________________ 113. DATECFE"ffRY !. PORT OF ENTRY INTO UNITED S".'ATES ----," -- - _ _ _ _ _ _ ___ _ 14. NAME_O_"_V_ES_ SE_L_O _R_O_T _HER_ _M EANS 0 F ENTRY 7, 16. CERTl"ICATE 'lUM3icR i. NAME ON CERTIFICATE 7. :JA .,.E ISS!JED IVETHE FOLLOWING INFORMATION FOR VERIFICATION OF N·ATURALIZATIOH OR CERTIFICATE OF CITIZENSHIP I. ADD.'lESS WHEN CERTIFICATE WAS ISS:.JED 00 NOT COMPLETE THIS BLOCK RESERVE0FORGOVERNMENTUSEONLV ----, · I 19. NAME AND LOCA-:-'.ON OF NA TURALIZATION COURT OR 'MMI­ ' GRAT ION OFFICE IS stJING CER"'."1FICATE: OF €/''.'IZENSHIP ·· � 1-- b)(6);(b)(7)(C) I :JAT£: 10ct. fHE RECORDS OF THE IMMiGRATION AND N ATUl'lALIZATION SERVICE REF�ECT ,HE FO: l0W 1NG I ✓ -."X.;C:f . ERIFICATION OF INFORMATION REQUESTED WAS MADE ON THE DATE SHOWN A .,. RIGHT _J '...AWFULADMISS 10NFORPERMANENTRESIOENCEON ____ _ ______ -·· -·· __ AT _ ___ _ _j NATU9ALIZATION INFORMATION AS SHOWN ABOVE IS CORRECT. ]. NATURALIZATION IN (COURT)-------------- ON !DATE) ____ _j ------ _________________j AT(LOCATIONJ ____________ _____ ______________________,______ _ ] DATEOFBIRTH ] ARRIVAL RE-CORO DATED J UNABLE TO 1o'ENT1FY �NY RECORD 29 COPIES ATTACHEOASREQUESTED from husbands file. _SHO'NEOSUBJECT"SAGE ATTIMET b)(6);(b)(7)(C) Your copies obtained --- -------,------- -�------- 'RIVACYACT ENTIFICATION D IDENTITY ESTABLiSHEO IN PERSON DOCUMENTS ATTACHED SIGNA { 0 G-652 Atfidavil 2020-ICLl-00006 474 , •• - l .. . . R -1 1 , ! -----�T�lT�L�E_i:====================::�==t 1100,�•�d By: ._·•_:i:1_ i . ·I -------� !1 '..PORT ABROAD FROM WHICH :..EFT FOR 'JNITED STATES j ---- ---- -- -·--------, D/1 , E lmmigr□tion and N□tvrali.ialion Service MEMORANDUM OF CREATION OF RECORD OF LAWFUL PE�MANENT RESIDENCE P.oce Milwaukee, Wisconsin >------------- --.A22 732 9 i8 Status as a lawful permanent resident of the United States is accorded: Nome DAT, Of Bll(TH January 3, 1953 Ka:r.iyar SAMIMI 2014 Evans S�reet, Apt 21 Oshkosh, Wisco�sin 54901 Street Address PLACEoT BIRT!-< Bahar, Iran COUNTRY TO WHICH CHARGEABLE (1/ anyF None PAIORITY CA.TE 0 Suction 212(0)( l-4) cert ifirnlion not NONPREF ER ENCE, ref-/ 7----, L___L____________j-',._�--- DD MAY . 9 / 179 jc:'i,' ;,:20 ,t ,:?.; the applicant es'.ab',ishss \hat he '" a member of o pr·ofessior, 01 c ;:ierscr wi:�. e;.;-:ept,o•,·11 ability fn the scrences or the arts 110' 'r.c 1 ·.;ded ;n the Deocrhner-t 0.! •_nbc r ·::. Sc h edule A:,29 C;::R 60) provided o certi',cot1on is ·ssl'ed o-, tfi,.:)' b'...:; 5 2·· t:101 he i: 'Ni'hic-. S· :heduie ,t.. ,:;,- th.or 1'"0 i prov sions o( Section 212"(o)(l4;- of the .�.ct do not apply to him; (3) thA dote r:,7 w�icfs 0� ar.i­ proved · valid third or sixth p;-eference v,rn pet"!ion in �!s behoii w'J, >i\ed; or (4;. fr,e 6-:i e cl.""1 --application for certifico;ion based on a iob offer was acrnpted for processin�1 by any ofi:ca within the employment ser,,·,c':! systen-i at the Deparlme ,; (•-i !_at-or, p�·r,;vid€c ;�.e cerii:":ca'io7 applied for was issued ::,, nonp,-efe>l:"nUc p-·"J r itv ckit,-:,, c~ce vrobi,,hed, ,� rf'.'Oi '"'.eC '.),- 'f'? c 1 'e.1 even !nough at the lime a ";�o nuM6er bec.ome:. c;·,·c:: 'rJb;.,, and he ;� ;:,i'ot\i;ri :J "'Of'(lreferer::e v:�a number he meets the prov•s·:o'l� <.Ji S2-·.:,:::i11 ?12{,Ji,":4 ��f •'r,e ,\ct f.:y 5'.)C"' S -,ec'l� ;:, f •�e ,.. than that by wh i ch he origir.al:y es' -:::ibl:: C.. ed en:'· 1ie--:-;er' h:: fre 1 '. ·_}:,,ye·ern'>c'i! p, ;~,_r','_i' dr,\'::'. l.!ill..Q!S_c..E.RII_FICAI!..QH_;_ Check and con·,pieie r'½e b1ock rego�d:1--2 .�er•ifr,cr;,,.-;�,s 0n t!--te t,y:-,·. ::is appropriate in a nonpreference cose. £<.E�f\_RKS, If the visa r.umber reqL 'ested i� base-d or Se('ior �'02 1, b 1. ,_: 203(0)(9) of the Act exp,a,r· as oporo�r1c't, ,n ··�er,or��· !:-'ocO<. 1, ,), ,3, or : 4·, or Sect,on : Q_E_\.A_Y_IS__OLLCL When the Se•v:ce /T't;51 obtn r· o v·sr1 -� • : ·nber ': -o.;r:i._ f )--e i)e�c" ·,·(� r,• �•' Sh!e -.::before gron!1ng pe < r;-inne;i' �e�1der:�e. _-the:: · :et� pcrt·or �• th,c forrr, r,ot1fyin;; o 1 �� ,e c. 1=I -.:,y s mailed to the apolirnnt with c copy to the atforr,ey of record. !n repr,0"�ente-:i ccses '.h£ ::;,:::;,-�.e; -" is notified of the oppro\fO: , :,'. 0,1 o�µ.,c,:;t.on ::;y h;rnishing him -¥ith a copy of tt"\e n.,;,11ce. wh;ch is port of thi-s fo"r-m 2020-ICLl-00006 476 I APPLICATION FOR STATUS AS PERMANENT RESIDENT ----------- -- --------- -- ----- Fo.rm ApproveC O.M.8. NO. 43-·rl0400 ---- - -- ------- _ b. I :'1ave_._,__ orothers ano s, and associativns. ;)-as� or present, in Which 1 ,avc held rner,-;be.rs�i;> , ... t?'le l.'�i�ed Sta-:cs or a fore:g.': cou:,�ry • .Jnd t..,e perlods a.nd places ot s.LJch .membership. (U yo� have nev2r neen � r"tC'Tlber �f 3r,y org�r,.:.!atfon, state ' 1 N::in�'t.) 1 0 have C]' have not bee;: tre.:1ted for a mcn�ciil Cl herder, drug adc!ic1:ion O" a!cohot:sm. (lf :;otl have been, explain ot"l separate---------------l sheet). 0 have 3haoJe nr')t been arrestee, ccnvicted or co,"!.fined :r! a pr ls.on. Pf ycc ..,ave t,een, ex;;;, ain on separate sheet). 1 [l have O J-: ave r . -t'lave not been the beneficiary of a pardon. ar,nesty, reilaD1!1tation decree, otncr ac! ::it clerr,ency ur St'Tlilar 21ction. (lf yow have neer?, 1 13e1 upiain_ on ,�parate sheet.) .. � .,ave rot received any ;::iubllc assistar:ce. (If you hove, cxp:..stn en separate sheet.) !:XCl:.P"" AS DTHERWISf PROVTD!::D tJV L.AW, ALI CNS W:THIN ANY OF ":"HE" FOLLOWING CLASSES ARE 1'sOT AOMiSSIBLE ;O THE UNITE"O STA"':'"l:.S AND ARE THeRC:FOHE INE:..IGIBLE roR STA"'."-.IS AS PU\\1ANENT RES'DE:-.TS: A11e.·H who nave cor.-iril�tec! or who rave bee:: conv• :: �ed of ct cri�,e i•�vclv!n� rior.J,t t1.:rprtu�e �dccs --:o� :-�c,�1�.e n\\r..or traffic vio'Jtlons); �iicn� ·.-,�o have been engaged in or whn 1nt�nd to en9agc In a'">y CO:"t\:"'!1C'cl�\'.!ll.!"C s.exua� i!:tiv::y; alic11s ·.-'i�O ,lre n." a: .:."� t:r.,c t,ave been. ana,cl"''H5.. or !';""".eT.­ bers o! o, affiJiatec: with any Corr,mur;is� or o!her ·.o":.a,•ita,:Jr'l p�t:y, inc.,·.:dil'.9 .ar,y s �d•vIsion or affl ia":.c ·.t-crt?o'f; alie�H �'le:: �ave -a-d1,#::-ic:.l�c�j Cir hu9!-:t1 cl�t·.er by pcuon.al utterance, or by me.1.�s of ..,ny wr,ittcn or prrr:1ed matter. or tt'rou9I" 3'fl:!a�ion With •n organ\4�t;oo, {l) c�posl�ion �.::, organllcc sioverrH::ent, �Me overthrow o' qovern,�1e�": by t-:1•ce er violence, {rt1} t:-ic �ssau1;lnc; or Kllllng of ;01Jc�·tr"1er.t o!-'idals o-o��..:w of !•1e:�:" off(c:al c�arac;terj (tV} t11e u'l'lawf..1,1 dostn...:ction of property, (V} satio!a9e1 o: (VI) the d0=.�t; .. <:� o� worl:, :::,)rTl.-n'..JnfS.n", or !ne establ:snr-:c:·: \·,: � 1 �o c1"19aoe rn or�j1..dic,c:! a�tl•1itics or u.�l�w•t:1 c1c�:v1tles c� a !.�bvcr!i:!'. 'e ,�J��:,c: tot;\/ltaria,1 dic�atorstitp ;r t:ie u,ittt!d Sta�us: �Pens "'-'ho .n�c-"':d 6 al lens wt'l o nave nee:� cO.rlvictcct o.r vlolatto:--. of aoy l.:.w or res:.,1;Jt1o!"l tc1a1: n9 ro narcotic dr..J�i or mi'.lrlrJt:ana . er who !'lave be en 111:cit '.:-J.� :, :,.._"=,.., i:. a.ssi1�;09 2.1·yo:�·or a1 iens tP enrer tt-,e L'ni!.ea Sta!es 1n "-'toJa:.ion o' ;av•� J'.tttr�'!I w:1:..i ' N tlO t,uve been '.rvo:vec .. �nc1; ai1on� Ir: r,,arc!��ir. drugs. or milri'1 I1avc �pplico 'or exen�ptlon er c::sc�ar;e fro� train: .... .g or SO"v.'ce 1-, ·.tie Arr""ed. For:es o-f :'r,c U:·iteC: S�dtes r:n �•"If! g�:J�:"\� cf alien age ar:� v,,•":V J\�·.•c oeer"I relieved or j[schar�ed 'rorr suc.h �rainin; o� �rvice. /\Hens w,-.o arc ,ienta:ly retardcC, i"Silne. or have su;�cred or.e or mere. at�ack5, ,.� :n'>,, .. n,ty: al;en !.: at1JiCtE!d wHh p�yc� opatn le personality, s.ex:,.14.1: C:cv· ol:ic--, r-�.---:�al defe-:t, �an:.o�'c: � ru:'.) dddic.tlor, c "l �on '.c .J:coh rJI :�r:-� or 2.:'ly I.! anl.)t�ru...:.s c .1ntagiou� dh.ease, al-ens who have J ohyslca: defect, cn�ase or c11sabill�y il "' fecting t�e:r a.bili!•y �o ea ,. r a ;1v1,-n1: allen5 wr.c are paLJpers, prc.'"f:�s::; .-:JI t:er,gars or v.lgrar.ts; aliens who arc pc;yga.":11Sts or advocate po ,-;,Hr Yi a.'!ens ::ke:y to occ.cn)e � p:,1.j.Jc cl'large; u1:1::ns wr:> !1.1ve-becn e,.c.u�otj frcn-, !he Ul"l:teo Sta�es. ·w1tnln !he past ye.,.,., or who at a�v time �ave c�e11 cepcrteo •rn,...-: -::he \...'n ,;1t .'.lny t =mc !'t�•,e e>eer. ,·c...,_�::"e'1 • r-::,.-, ��e Uf'\lteC, Staus at ,3ovetnmcnt ex;,cn>e; alr&"'i5 who l�iive attempted to pr�curc a vis:, by fra•.,d or t"i"":lHop.rcsen!atlon; .al 1C"> w 1:'.) "":.·c :i,­ parted from or re.m�incd o...itslde tt'o u..,:�ed' S�,lt�> to avo ·d rrllit.d"Y s�:·-,..-:cci ifl !in,e 01 war ar nat;cnai e."T1c -- 9t:nc.yi alion5 who are forrr.c� C-)(Cl-,dr.ge -visitors who Jre suc;ec� to tll.o� have not compi!od wi� ... the two vcdr foreign rcs::::10 ,..., ce .�'l!Qu)rc'.h e::-: t. 1J on 1 o any of t�e foregoing classes a;,p:y to yoJ/ 1 Jve, '):- NO (It onswer ;, Yes. explain on sep•rate ,neetj. ignaturc cf person preparing form, if<>lher tnan applicant). I ce�lare tnat Is document was ;,tepared oy me at the request of -the ap1Jlic��.t a:1d is scd on a:1 i1forrr.a!ion on wnlch I have any Know'.edge . Ccc: .... pation: UNITED STATES DEPARTMENT OF JUSTICE - Immigration and Naturali1.J1tion ,020-1cu-0000G 477 Service Narr,e (Family) APPLICATION FOR STATUS AS PERMANENT RESIDENT (First/Given) s c'.�:-.: :: .: [Micdle) Male �onn Approva:j O_M.B. No. 43-·R0400 4. ::).ate of Birth 1 ha,Je ?Je:en married tlm.e.s1 including my prcs�nt ma:rria;:c, ;, "1ow rrarricd. (It you are •1ow :iiarr;ed gjve tr:e fo·.1ow:og:} a. Numb Imes my htJsbond OT w,fe ""' been married ee •arie) er,..,,. ll',l P g,vc -a,a � �;� 1 .• r f· N husb : ;'ft er wife res,c!esf] Wl�h rne 1 a, to each as In 15. a. above). b . I have -' e;: e� :_� �1€1,�e �-J:.,tt': -:-� ,..., �i---;c"... _4'_�--c,.,·_,,.._;-;-----=',��.,...,.,_;-;.,..=-r-'-'---,---1(b)(6);(b)(7)(C) � �r - !�i -"--������-��Y-• -&----1 -4'! M "r�:::, ._... 1 �p�rmanent res · Y �irrli•Y:1.re aao aPp' YI�.� --'-------L_____J-- (b )(6);(b )(7)(C) -ror ------------ 1. - -- - I below "ti organi:z::atrons, societies, cluos, and .associati:i;1s, ;:>a:s� er f:!rese;-it,�i;;�hici,-�a�cheld-mef""'bersrip i!"' �r:c United S1ates Or a tore;;ir, co·Jn1:ry, and the �er:ods and places o� sue.ti mer.iben;hic. ( I� you nzve never been a mctnber o" any ofgani!aCo,i, state ' 1 '\,,cr.e".J ·.is.� r I 'lave one . . �.,ave rio-: :>een !reated for a :"':"':en�al d;'io:c1er1 dru� �ddk!fon or alco�oi:s"':'1. {lf you have been, eY.p:ai:1 o:, scpa.rate shee�). - ---· ··- -- ---------------- L ,.__J have i3have r'\Q': been arres�ed , co�vic::ted or c.onfined In a prisor.. (If yo ... :ave be-en, ex::;la·;n on SCDilf.Jte shee"'.:). ________________, ----------------------------------------------------------------� you t�c.1..-c beer,, ,........... tHJVE r.□t �een the .beneficiary. of a piHdO"'I, amnes�y, rehiUb1Ttat:on decree, ot!l.er ilC.t 01 c.:em e:1cy o, slrni ar .action. ( have I. I � expla�n ?n icpar��e s�.eet.) 1 .� ----- � nave not received any public a�sistarice. (If YOL! r.ave, !:Xp1ain on separate §hcct.) l. I. CXCtY'. AS C1-HERWIS':: '"lOVIDED BY LAW, AUl:.NS WITl·◄l'-1 ANY OF THE "OL'-OW'NG CLASSE.S ARE. "<.s ::)f :n-.u­ nay; 111fens a�fllctecj wltl"', psycPiopatnic oerson2.lfty, sexu whn �a ... c .:>ee-n cxc..L:ded t�i:: L.: 1lted s'tates witt.1n !!l·e past year, or w---:c n� �r1y ":.ime riavc baen depor!"ed *ror.-: �h e United Sta!es .. or 1Nho at -a:1y :;,.-,e !"'I.ave be�:, :·!:.T1--::·�•i;.-:d 1 1 cv: � 1 fron� trc .Jn:tad Slates 21t Goverrime:.t expense; ai'.1::::1s who have .itterr.µtc-:j to procuro a t;y 1'1";:31.1:j o, r.-:f"Srcprese,!.at:Qr.; a:lcn-s wno h�·�e ::::h;:­ p.ar!ed from or rerralned outslde ':he Urirted St.at-cs to avo;a rnllitaty serv:c.c lr. tJme of. wa1 or natlocal emergencyi aJi-ens who are fcrrner exc h,H·,ge.. · visitorswho_are subJect to out na1,1e not co,...,_plied witll t111::! two vcu "ore:g--: res iae-nee requircrnen�._ vis.:J Do any of �he foregoing c lasses ap;,ly to you' -1 Yes (If a.oswer is Yes, exp lair, �n separate shcot). --------------�------------------------- --------- �- �- ,signature of per.son prepari:,g fotm, i1 o tJ)er than appli::ont}. l declare tha� thJs doCtH''.'1et1t was prepared by r,-e a� the reQue.!it of the applicant and is ba,ed on all r'nforrnation on wnic� I have any knowleoge. 1 Ac.dress-of per�nn preparing fotn,, i" 0:1,-er tha., applic.ent Date: UNITED STATES DEPARTMENT OF JUSTICE - Immigration and Naturalization Service 2020-ICLl-00006 478 V I,�- 5b,.$ �;/ , , do swear (affirm) :h�t I know tne co�tents;r:tils application subscribeo by me iscllldin� L __· ------·•------ the attacMci docJ,nents, that :he sane are true :o ,o,s« 0, m, ••: m, M', / J tor f ; we,e "'•,e.,..-_. ____ Subsc,lbed ana sworn to·be�ore me: by �":-e above-nam4?d applic.an� at Jj_{Lt 1{1d,A..,\::r•:;:.i..;._'___ __ ✓- _Jb)(6);(b)(7)(C) ( 5 ' (·M��ication r"ot �o be signe.o below ..i I, ii app,iC,iH'.,,! appears bo�ore a:1 o1ficer or �·:e 'mm.gr.'!":ion and Na�·Jraliz:c>�:a:, SctviC.t:!: tor exarr·l:iaticn: ,__, "'_1._______ f ___________ , Y---�--__ --•-· f_ do 5Wear (affir:n) t .. a•� I koow t�.c c;o_ntcn�s: o•/ _!_ :, is a.i:::pllca�ior. si;.b!.Cribed by me ln.cludin� �nc attacnec: doc:ime�is, tt,at t/1c same are true to the !:>e,t of r-,y Know:cdge , and th�! !he correction, n ·'tc,ed ( / by me or a� �y reaue.st, ard that tt-is appficaflor, wa§ sigr.eC by r::.e wit� my !.;II, true r.arne: ( _ to [ J were mad :.:- __ J&�#:/ (Comp.lete and true signature ot aP�licantJ (Yea (b)(6);(b)(7)(C) :·�f :: •'*,< . - ·• , •· · - .......... . 2020-ICLl-00006 480 .: . l - Form App�oved 0MB �O. 43·-ia _J. ·�,; ===================================�' �· .5-_ r�· •······-..."-3 cr-t> •', · . . . . .:J ( ) , Petition To Classif y The Status Of An Alien Relative For t, FEE STAMP ; 203 a)(l) 201 [b) SPO use: - C!-l ILD = 20l(b) ?AREI\T 2. ·�a< bor.�: ---· 9. (Month' ) '(vea°r, !Day) .�u :··u P t (Towr or City) in: �.q k i..: i 1 �, a.tf;-_ e e If you are a citizen of the United Staies, give t�e following, •· Cltizensnio wos acquired: (Check one) i::J 0 through parents l/1rou9h birth in :he U.S. (Apt. No. ) (c/o if appro p,1ateJ ,l. My current addreirth of ' beneficiary's chtld ren! (S:ate or Provln<:e) \\•1 0 th,cug�. r.aturalizatlcn (Numoe, & s:ree1) ·...�. (Co�ntr y) S. h .. [i through mar,lage -= { '" (Townor Cl ty_ i p-Co de l J___ -� S 1_a.,.te s.. z� #2. 2. Last address at whic.'1 I and my spo�se resided toge!her (Country) ( State :Jr Province ) (TOW,"'. or City} . ·- (N·.. mt:>e• ano Street) . ...., .. ...... ,:- ·-- ----·---t FROM (lll'on�h: ( Year} -- -TO (Yoar) {fv'on�h l ,. .. -----·--------- -4• .rt this petition is for your spouse or child, glvelheioi'iow:ng: a. Names oy ye:... -- \J.) :..� ::: .1 - :.7) OATH OR AFFIRMATION OF PETITIONER na1 the staterner'lts are '".:'l.le an I swear (aff;rr:,J tha1 I know the contents of !nis petition signed b Sign a !Ure of Petitioner corr,c •. b)(6);(b)(7)(C) ).4,.. Suoscribed and sworn to (at!irmedJ before me (SEAL) .\/If commission expires (SI SIGNATURE OF PERSON PREPARING FORM IF OT (Title) 1i< oocument w�s prepored by nio at the request of tlie oe:J�io:,er. --- --- --------------------------- -- -------- ------------ -----------(Date) (AO dress} (Signature) Received \- Trans_l__ n +-__ R_e_t'd. -:-rans Ou: comp1e:ec f7 --_·_.,_________ _j__ ____........, 197_9_L_ __ MA _s___ m t-:30E(3-1-78) 2020-ICLl-00006 481 I .I. UNITED STATES DEPARTMENT OF JUSTICE IMMIGRATION AND NATURAUZATION SERVICE Milwaukee, Wisconsin 53202 FILE NOc_ A22 732 _918 MEDICAL EXAMINATION AND IMMIGRATION INTERVIEW Kamyar Samimi 2014 Evans Street, Apt 23 Oshkosh, WI 54901 INSTRUCTIONS FOR MEDICAL EXAMINATION A medical e�am1nat1on Is necessary as parf o/ your app.I 1catio.., for adjustrnc"'lt 01 status to permanent 'esidenr :! yo,,, t-ia11e ,t'ach"d your <1f!eenth b1rthday you m�s� IMMEDIAT['LY oblain and br1ng with you when you appear for yol)I" rnedic;i• Pxar,inat+of' . ;i seroloqy report ;ind 1 •·· X '7" chest X ray \1 !rn. with a reaC,ng tly a l'iccnsed phys c,ar :nterpret•rg u·,,ci x-,av r;Im T'le seroioq•c r,-,s: 11ust �-"' performed bv a labor;i:ory aop:oved by a state or locill '1eal�h deparlrient The X-ray r,ri ;;ind serolo;-,c tesl tor syph1l,s rray rot be more �han 90 da1/s old YOUR MEDICAL EXAMI\JATION CAN\JOT BE COMPLC:TC:D WrrHOL.:l THE '.1i SEROLOGlC R[POfH RAY AND (3; READING OF THE X 9 . AY FILM 1:,; X PIP,1S•! '''l'P. �lso !hP b'lXflS Cl'Pcked 0 � belciw w·rt1 rC<')'ird to ycitJC r""'.l 't.�I n�;ir,1na\1ry1 Please obla1e yacc serolog1c ,,,e>art. X- •av r;·m�d •caG,nc proro�lly Yo" mav te1Aphon" ',O..-: s:�:,. ,,,. ·,..,ca• >i,•,,�•� Jeractsif'f1• 10, •h,.. ""'"" "' on approved labor�tory wnPce you may or.ta," !t-esc fl.!'.'.'1.!J. �C'" a�:1 � es of 11'1, s 1 c�;•r .,, 1� vo., w�,..,. yo" ax•car 1c,c ,.,,,.,,ri;i,,on >,v a phys,c1as of the cJ S Pabhc Hea:tr S,.cv,cP tor wC·c,C "" a�po,�:ro.,,-,t r.as b.,;;:;;-r";;dP at !',e -�1;,r:e a,,n �"•� ,rn,c�le� �""'"" ADD"lESS I I l ." '1•as>" commll"' �.,:» 1C"'Tied·,1:c'v w,t� !Cr ,:�!�w l·�t"rl �r 1•�1r,1an nr w,1r , �,. ,,, rr,. �M-,·,,, ,,�-, "" '�" c,•t " c,•n :,,,: • a 1,sl ,s :o,:�c:�e j ! 1: 'c, ;,sc,., •o 1 wSa'. arr.,n�PmPrl� \'�i this ,,�,1r,1:n,i1 ,nn m '-S' �-- :ia,r1 i,, ,,,., P'iYS.1CIA'-J'S NA,\,IF A'.'.lORFS.S ANO Tf ��PHONF 'JUMRFR See attached ist. P t'ase snnw :h,s lert�r !� a,.v laho,ar,,,, perf•,rs, �.; •,•s'.s �'s:i ,.,.,r I"" ,·.,r,,ns r,' '" s ,.,,�,,,,u.�,, �-,i • ,rr·•sh hl'n ·;,·,,n vo·,r si • 1ra'. ,,,,,_ w".1'�:i c o·,s nr,,sPrH;c ,,.,, ,ncl t:s,�" ,,re h,� -,·:· ,,, I ------TO PHYSICIAN�PERFORMING EXAMINATION -- - THE -I PL.fASF OR"IAl'-J 'rff": APP'L 'CM-iT<; S'G\JAT'Jf-lF i,'-J Tr!f SPAC[ P.9QV,'DfD A, '-JD Mf::J:CALI, EXAMi!,� HIM ,·o;;r EllGIBIUlY tOR A::;• . c I .ll)SfMFr--..T or STAT: .JS IF THE ArPLICA'-,l 1S fR! ,- c• •vff'JISAL ' Jl_FfCTS ::SFC !N sr r"':'1 0", 212 :A: or:: TYl IMMIG9AT!ON A\JO r--.ATIO'-JAL,TY ACT ENJORSf THIS COPY or ,·ol'lM '-48fi1\ .'N T!-iE SPACI PROVID[D ANO HA.,\JD !T TO n-lt APrl_.'CA'-f! 11\ A SF.A'-E;J E.'JV;::LOPE FOR PPFS[NTArior,· AT ',:S 11\,, JC,1,r-.. T ',S r,'(")f 1'Pff: OF sur;H MC::JICAL I DEFFCTS DO NOT SIGN THIS FOF(M \JSTFAll WRITF ·su=-: FS 398 ,N THF PHYS1Cl,�N'C, ' src:;NIITURF R! OCK AND PREPkRl I M[OICA: CERT.'>iCA7E ON ro•w �S-:J98 AND !1",, \0 T TO Tf--,_ICA\JT 'NA. SEA'.i::D i�'-JVElOf>E': ~oG[-','[R wr:H TYiS COPY 1 T I OF FOR� 1 486A F0,9 P.9FSENTAT.'ON AT f-'IS ''v1MIG!1ATION \J ERVIEW '.IF EXAMl\'flllO\J 'S CO!\OUCTED BY A CIV.'L SUAG!-or--..· INSf-RT 1r--. · F::NVF.:...OP[ 90T''7 COPlf,S or F09M '48/)A, X-RAYS A,'J,') LABORATOHY Flf.'"ORTS AN[) TWO CQPlf-S OF f-ORM rs ::198 I I" APP LICA,\H IS \JCT FRFf or MFC 1CA1_ DcFF(:TS ', I L_ 1 �fRi"IC" -,iA- y Tt--,E A'T I SIGI\A r � [ r k I X I -_____ -_----:- DISTRICT DIRECTOR '7F.l X RAY r,•J !J Sl'-10'.ClGY Ri l':)R1 •RI OOD ffST, RFI Alf TO MC I PENALTY T•1cv1rµ� ',r'l\�1 - ;>1-NAr1,,s rem ��DW1. �r,1.y �NC WIIF\h!V [A 'Slf\1 ,V, ,-,,,, r,'Nr,,, , ,;(; > ""�'f'% __ --- - I ,,Pf'I ��; n�· ______ _ 2020-ICLl-00006 482 I Form 31)provcd UNITED STATES D.EPAR.TMENT OF JliSTICE lmrn1gration Md N aa1raliz.ation Service 0MB No. 43~R423 AFFIDAVIT OF SlJPPORT (ANSWER ALL ITEMS; nu. IN WITH TYPEWRITER OR PRThiT IN BLOCK LETTERS IJII IN,K.) Q,<; l±KD,,", d /Cily) (ZIP Cod�. if in /IS.) (Co1J11lry) being duly sworn depose and &ay: 1. I was born on --------- at ------------------ Also, 3nswer cilher a. � or c, as il)pro(Dore) (City) (Co•ntry) p:iate, if you ue not a n3tive born t: n.ited Sr:a.tcs citiu.n. (a) Jf a Un[tcd States citi.u:n t�rou�h naturaJlzat.ion 1 glv::: numh.:r o!' certificate of nau..:ra.:i..ation (h) li a l.:nited States citi2co L'u"oup,h p_arent(s) or marriage, give nurr.bcr of own certilicate of cit,1.enship If none obtained, attach s·tatcment explaining how- citizensh1p derived. (c) If an alien lawfully admitted lo L�e United States for permanent residence, give 'A' number ________ _ _ _ __ _ _ _c./ 7 /,,. ----------- .,.___,_l ,__....,.._'--f-.L.. )l'?�-I-· �L 2. That lam _2.k_ years of age and have resided in the Cnited States since ____,A "-'--1( 3. That this affidavit is executed in behalf of the following person(s) at present residing at ________ _ _ _ _ _ _ _ _ _ NAME SEX AGE COUNTRY 4. (Amounts shown in answer to this qL1estion must be in United States dollars.) (a) That I am employed as, or engaged in the business of at d-�D, 0RE..<:iCJ\) A1i'E(,Udrenj banks in this country S O MARRiED OR SINGlt Of 61RTH ME c_HAN I C.... with RELATIONSHIP TO DEPONENT ()s�\ KO SH TI< L,l,( \(._ (Name of concern) 0, lCD. (b) That I have on deposit in savings and derive a net annual income of S / (c) That I have other personal property, the reasonabie value of which is $._____ (d) That I have stocks and bonds in the amount of $ , 0 ma,ket value, as ind:ca<::d on attached list which l ce:tify to l;z true and correct to the best of my knowled1;e and belief. (e) That I own real , w'th mort gages or other encumbn :mces there• estat; 2020-ICLl-00006 483 RHATI0NSHIP TO lv":LFE ME 6. (To be filled in, if appropriate.) That I have p�Yiously submitted affidaYit(s) of support for the following person(s): � Dai, submitred Name 7. rro be filled in, if appropriate.) That I have submitted visa petiton(s) to the Immigration and Naturaliw.tion Service, on behalf of the foUowing person(s): N,= Date submilled Relario11ship 8. That I am willing and able to receive, maintain, and support the person(s) listed in item 3 above. That I am ready and wi/1,ng 10 deposit a bond, if necessary, with the Im.migration and :"l'atura!ization Service to guarantee that such person(s) will not become public charg es during their stay in the United States, or that they will maintain their nonimmigrant status if admitted temporarily .ind will depart prior to the expiration cif their authorized stay in the t.:n[ted States. 9. That this affida,.it is made by me for the purpose of a%Uring the United States Government that the per.on(s} named -in item 3 will not become public charges in the l_j ntted States, 10. (Complete :hi< block only if the pcrson(s) named in i:cm 3 wiU he ill the U.S. 1emporarily,) That l = do intend, :::; do not intend, to make specific conlribotJ.ons to the suppc,rt of the p,en;on/s) listed i� item 3 abo·,c. (If you chens. For e.umplc, jf you intend \0 furnish room llnd hoard, stale for how long and, if money, state the amount in Umted States dollars and st:1.te whether ii is to be given in a lump sum, wetl:y, or monthly and for how long.) _____________________ 11. That my reasons for. signing this affidavit arc: EXECL'TIO� OF A�'FIDAVff. You must sign tr.e affiffidavlt may l,e sv.orn to or a!'"'..irrned before ru, jrnmig.r.Ujon ol[tcer without the paymcm of fee, or be­ fore a notary pu.�Jie or other offic,.:,: authorized to a�ir.lstcr oath< for genera pllrpos�, in which ca,.e the official seal or C(:,-tificate of a,JtOority lo administer oaths mus! be :iffixed. Ou1sidt the L"11ited Sta/es the affida\�I must he sworn to ◊r affirmed before a United States consular or immii;ra!io11 officer. Signature of person preparing form, if other than deponent declare that this document was prepMed by me at the request of the deponent and ,s based on aJI informatmn of which I have any knowledge. S[GNAT\JRE Address: SUBSCRIBED AND SWOR� TO BEFORE ME THIS ---- day of _________ A.D. 19____ (S} depon,•m1 (Tulo of officer) 2020-ICLl-00006 484 ... ! / !)ate· D 5 "DJ n.!',. · 5 H ·-. ---·-· - ----- - - - ■ Oshkosh Truck Corporation Box 2566 Os�kos�,. W!s. 54901 :.,'SA P:�one 4!4 235-9150 TELEX b)(6);(b)(7)(C) .·I May 8, 1979 To Whom It May Concern: Mr. Kamyar Samimi is employed full time at Oshkosh Truck Corporation as an assembler on the 2nd shift. He was hired on February 7, 1979 and his present pay is $6.54 per hour. Personnel Department 2020-ICLl-00006 485 -- 11,FIRST WISCONSIN• OSHlff. ._- ..y· NAME: .,; .l Ii .l .f�. Kamyar Samimi FATHER'S NAME: Parviz MOTHER•S NAME: Allieh DATE AND PLACE OF BIRTH: J_anuary 3, · 19� Baha,r, I ran DATE AND NO. OF BIRTH CERTIFICATE:March J, 1952 DATE AND NO. OF PASSPORT: MARRIED: ------ #67 HUSBAND: WIFE: CHILDREN: I I, .-:�- (b)(6);(b)(7)(C) - -·-..... .::;:_,_.; .� ,' ' . ,. :· . DATE: November 6, 1978 DEPUTY CONSUL GENERAL OF IRAN - .: • . J 2020-ICLl-00006 487 -·- - .. ... . .. !�� .. -- �YJ; .i-,..i.;..·,t,J� ·------;--t,..'i:-b ,s_,,..J ,/ .,;;_}_,:_,,/�•, o \cJ'l Y .er<) ,,, ,,-!,)Jl_,...1 � .:,Lo.iL. i\,;i \;.. t;.;;i .,;,;, _jJ.J.; I ·" I ,,, 1.. •· " ,·, -·it'I{ ,_-. <:_-_ _:��l�s-;,· � ·i .. 2020-ICLl-00006 488 n? d? camamon 5mm o?IWLsconsin Board of Health To All Whom These Presenls Shall Come: I. M.- n_ State 7 Emma". bu of Vl?lai Sums- ucs. State Board of Health do hereby unify that the adjacent photograph has been compared wiL?I the original on file in thIs department. and is a Irue plum? graph of the original my. I have hereunto set my hand and affixed the seal of the State Board ol Health. this- of Vital Smm?ts ucpu ty. I I flu) du'l'd r0 RSI. 35 2:5; 5). i Wlum vital" - {22' . i BO 0F HEA RILGN CERTIFICATE OF BIRTH TH I'i tl I'll-uJMux. magnm mIr-I August .Il,n:1 . I Fl'l L. . \AS-ll; I . ?01.01! 0R ML. Dray-Z on I ?hi te uni-Tr?; !Tecnnical J?ngineer I 0.. ?Fun: 5. Ione Lucile (Sun 1v Inceu?hmubln? "Iiscansin 5. . . . heacore n. . AGE has-:4 II- . ?Hy: .. no I fisconsi: "9.41:3- 31011-wa 4 . '4.?ch SAM I: Lu? Ott MACE araus uh; ,e In no ?rurnramnmo N014: c. Ink. buchi'm [a (Sb-lem- hm ca: Id-n we Man)? [mar lime?he's ?us?:0 nub Lo :0 no}: (M mar ol uzmnm .I 3 TEARS a an IT. Father I ?71:71; that we: lac-m di?ur on the 4143(- imtod abovcl?I; We mu to: ENE-ANT BIRTH 1 .51 or 90 OTHER August 18, 1959 WING): ARE f.AEE-TO MIIIIAV Ul'IDEA THE LAWS·OF•HIS STAT·E·. ► ___.,....i,;.c._ ·' ______ _ 1----__._: _:._!:_;_________ i... ____ coUNTY; $TATE OF WISCONSII'/ ;=: ,, •. SI ac ...,.·Jlp. .... .. .\ 2020-ICLl-00006491 . ..... UNlt ' , STATES DEPART¥ENT OF JUSTICE , .. ,migration and Naturalization Service Milwaukee, WI 53202 • March 2, 1979 76/11 I-130E Kamyar Samimi 2014 Evans St. #2 Oshkosh, WI 54901 Petitioner: Diane Lisa Samimi Reference is made to your recent letter, application, or request, In this connec tion, please read and comply with the instructions checked below: D D D The infonnation requested hos been sent to: � Your request should be directed to: This will acknowledge receipt of your request for am endment of record under the Privacy Act. You may expect a decision within ______ days. Your request comes within the jurisdiction of the office shown below. It has been referred to that office for appropriate attention and all further correspondence with this regard shou l d be sent directly to: Your request hos been deferred to this o,lice for processing. Any communications conc erning this matter should be submitted to the above address. D C � On the basis of the infonnotion furnished, this Service is unable to identif y a record relating to the subject of your inqui ry . This Service, therefore, can be of no assistance to you in this matter. The information you are requesting is not available from the records of Immigration and Natural izatio n Service. A f ee is required in the amount of$ 35.00 . Money ord er or check should be mode paya ble to the "Immi- gration and Naturalization Service, Deportment of Justice". THE ATTACHED COPY OF THIS LETTER SHOULD BE RETURNED WITH YOUR REMITTANCE. � Fee retumed in the amount of$ ______ D Because no fee is.required at this time. ,-------, Because an incorrect fee was submitted. Fee for this service is$ ____ _ U For resubmission with the enclosed applicatio n. C ______ _ Response to your request hos been delayed. We e xpect a determin ation to be ma de by _ __ _ We seek your patience and understanding during the extension of time or delay which is due to: Sincerely yours, G-343 (Rev. 7- l 1-77)N GPO �20·20B 2020-ICLl-00006 492 UNITED STATES DEPARTMENT 0� JUSTICE IMMIGRA:10.-. AND NA1URALIUTION SERV;CE OM8 No. 43 RC417 APPUC,-.,fON BY NON IMMIGRANT STUDEI"-, (F� 1) FOR EXTENSION OF STAY, SCHOOL TRANSFER OR PERMISSION TO ACCEPT OR CONTINUE EMPLOYMENT ___ I I V' ••I M�""'V" OIJ r .. PART l-T_O_B__ E F_I_LL_E_D_N I _B__ V A_L_A_P_P _L _L_JC_A_.__ N _ T S_____________-1 t,;;.,M APPLYlr--.G FOR fCHECK AND COMPLHE AS APPRO?RIATE) I&) I 1 EXlENSION OF lEMPORARY s:AY '.O D 0 ____ ,__ P�RM:ss:oN TO 1RANSF£R /1.& I Jr t--!/...,.'1----------- ANOTrli:R SCHOOi PERM1SSION TO ACCEPT EMP.OYMEr-;: OR TO CONTINUE PREVIOUSLY AUlHORIZED EMPLOYMENT PRIN':" OR TYPE YOUR :'IA.ME EXAC":"l..Y AS IT APPEARS ON VOUR. ARRrVALaOE"PARTURE RECO.A.C FO�M 1·9 .. , IF YOUR MAJLING ADDRESS IN THE U, S, IS WITH SOMEONE WHOSZ::: �AMlLY NAME !S DIFFER.ENT FR0"'1 VOlJRS, lNSERT T�Ai"r PEFISON'S NAME jt-,' T�E C/0 BLOCK, I. 1.YouRNAME I ro � MAILING I c,TY/AoDf�o)) AOOR!c.SS IN U.S. t}.., No.J(U.1 ! a"1 ,. - I CRANT CLASSIFICATION p DATE O . . ZIP COOE !j3 J,,/ T/1� 3,19!!3 FILE. NUMBER(// Know,,) . � . w/117ej W&._:I APf;� STATEW/ F IIIRT lltRTH (Month. Dey. Year) COUN � ry-j \ 4. PRESENT NONl/"' MJDOLE _;.! R,'ilA_ 'vii IJ , r,/-l�• ✓rr � I 1 C/0 I INUMSER ANO STREET (Apt. IN CARE OF 3. oATE -:s AMJ MJ IFA �Y NAME (Cap_ital Ltlllrs) lc oLJNT OF' I JI ,q � 'IIf 9. PASSPORT NUMBER• zENSHJP ,o H u zE l lRES � ; r;,� /q � /f ,.·lue • or "Ha.ue Nol") I fi ,.,1-, n .,-I"' - PASSPORT ISSUED BY (Cou.nlry) AND EXPlllES ON (Dal�) ·= u:, I I - - -- : :.,. -� otior L b)(6);(b)(7)(C) - INCOME PER WEEK I "Y' - OATES SUCH EMPLOYMENT OR BUSINiaSS BE; � ANO EN 19. MEANS ANO SOURCE OF SUPPORT WHILE IN THE UNITED ST (b)(6);(b )(7)(C) 20. {COMPLETE THIS ITEM ONLY IF YOU ARE APPLYING FOR A ,CHOOL TRA,\JSFERJ I, M-J .!fQ+'1�r (ti m- \ .... I IQ Hove QHovo not bun o full-t;me studer,I at tho school which I wO< lo,! authorized by the Immigration ond Nolvrolizollon Service·lo olfonc! (If you c�ecked "Have not• ,loltt tt,o reo,on• folly) I am reque-sting this tronsfe_r because: 4TTACH '(OUR FORM 1·94-•oo NOT SE,10 YOUR PASSPORT FORM l-538[REV. 6-1-7�) Y 2020-ICLl-00006 493 .I. TRANS. IN -I HAI E BEEN EMPl.OYEC> OR ENG .. GEO IN BUSINESS IN THE UN BEEN EMPLO'fEC> OR ENGAGED f,',j BUSINESS IN THE UNITED STATES, COMPLETE THE RE:sT OF THE BLOCK. NAME ANO AODRl'.SS OF E;MPLOYER OR BUSINESS KINO OF EMPLOYMENT OR BUSl/iESS - RET'O·TRANS. 0 {; � .. , .. PART I - (CONTINUED) - TO BE FILLED IN BY ALL APPLICANTS 2. \. CHECK ITEM IA] OR (Bl ANO'COMPLETE THE. ITEM CHECKED □ □ (Al 1.1.M .t.TTENDING SCHOO'. NAME ANO LOCATJON OF SCHOOL I AM A uh, ve Ks ,"f';/ o'Shk'ogh w' co o-P (s«e Instruction No. 1; also, i/you ar� cipp'lying for <1 tra,ufer see Jn.str�clion No. 4.J NDI �� � I 6'.Lfqol NUMBER Of CLASSROOM HOURS I ATTEND SCHOOL WHXLY , j_ MY RE"-SON FOR NOT "-TIENDING IS: '" I WAS WAS NOT AlilHORl2ED BY !Hf ..w,iGRAllON ANO NATURA:IZATION SERVICE TO A!:ENO Tl-lAT SCl100L. � ANSWER rs "WAS NOl", Al:ACH A s:A:EMENT GIVING NAME AND LOCA110N OF THE SCHOOL YOU WERE LASl A�;HORIZE.J 10 Al'.END AND WHY YOU ARE NOl AT:E.'-l:J:NO T.�AT SCHOOL. O lj) DAY OR EVENING CLASSES (SPECIFY) _ ! IB ) 1AM NOT ATTENDING N.1.ME-AND LOCATION OF SCHOOL I WAS LAST AUTHORIZED SCHOOL BY IMMIGR"-TION AND N"-TURALIZATION SERVICE TO AT!ENO M �� �fl4 T I DATE DAT£ OF GRAD;JATION OR LAST I ATTENDANCI: (SPECIFY) I PAIT JI -TO BE flllED IN IV APPLICANT fOI PERMISSION TO ACCEPT 01 CONTINUE EMPLOYMENT 2.2. I OE:$11\J; PERMISSION TO ACCEPT EMPLOVMENT F'OR THE FOLLOWING REASON: IAI (a) or2romn.,..,... Country cl Nationality i CERTIFICATE OF Iran READ CAREFULLY THE INSTRUCTIONS ON PAGE 4 ELIGIBILITY Name or School (FOR NON IMMIGRANT •F-f� Universitv of Wisconsin-Oshkosh STUDENT STATUS) School Official To Be Notified cl Studenrs Anival in U.S. Mrs. I l(b)(6);(b)(7)(C) International Student Advisor Add;esa of Sdlool (Include z;p Code) Oshkosh, U.S.A. -� WI ... 54901 .. '• It Is hereby c-etlif'"ied as �oUOW9: 1. This c:emf'Clhl 15 being �totne s.tue2:ent nam.-d f't•1'81J'I for: {Chec.k C"'•l ' ·- ' ' ' • > . b. ConUnu•liul"I after• ter,,para,y abse� outside the U"lt.-d States. Hrs pnt!lentPY acahcrb:ed ..a.,.y. •" IP041An on o.. Initial att,mdar,ee� U,lsschr,ol. GI D . . . Fe"" J-!14 In M• �- ••pl- lnl.....111. clay.,,..�__. __________..;,____ ;...._ ____________ c. 0 Olll•rl•paclfl,) __....:,___ . J ·-- . 11a wMI be e"1M'Cled lo tar'}' a tun prog,.,m cf study as d91inod by imffligrallon n,;ur�Ho• ,8 CF� 214..:Z(IJllaJ. &l\d 111;s llutitutlon..(S<:l>ool.$w/'lich d..ore !he,,,...,vM ..,.......,e1y·o, p� martt-j to vocalicl"'lal.bus.iness.orta";:u•g• Jnstructlon mu3tcomplet• th• ronawin;; He wlll b• expac,tkt tocany a mi,,fmutn ot_dLclockttours a ....kl >fismaiorlletdatstudyis . . . a,,dhelsexs,ecl<:\lon(n Enilh'>, whlel>wl" c:onolslol _______________"'--____ ___________________ c. 0 Prn!icie,,cy In lhe E11g,llsll language Is no1T9C1ulred. E,cp1&;n:.• ---------------------------------------- , , . : the aven1g• 1Co1dem��ye-arrorolh1tr &r:11domlc•term} cOS'! l=2=-__ mCln.th:s} cas! for tui!ion and fees Is s. 2 08 0 2 07 0 .Tel01 co,lf� ac:ademio-l,6ar (01 olhM ...-,i,.m;c•_lerm) •• estimal"!3_i.;,.. s 415 0 (E.pen,...lotlhe sum mar' . SL Thllii pr·es.nt acadernic-)'ear(or cttl., at:2demlea4:erm Qt'__ . · fer 1,v;1111 and lnc!deftb!. e.pensM ;s4'Sllmaled ta bes period ars notlnir;:luded t11 ll'le-sa figures.) __ me�,�� Is � ....,6 ,._"'-" 00 ,.___ , b Esll-ted cost ot llvlniz � Incidental -� too the summer period (oratt,et non-a,:edoml� P•r1ocl"J ol __3 . . ' ti- Indicate how the .:stud1tnt 11•Ptcb to me1tttha 1tJ11::P1tn!� esttmat.c& ln Items� ■nd 5'b abC"ll'eby c,o mplerJ� Ill■ tol�itu,; [ched<. and nu in&> o.pprocu+.t.ta): tOCM'f"'/ aruu CIO'U,.,.of study. Thedl•ofo�lss _______ .,., ___-'----- 0 Sctu:ilazsh,p/g,f'Ar,V!oan from enorh11r liOurca (�a<;ify source: ____________.__________ _ � . _ et s________ e>e< ________ unlll . __ __________ � PeP'$0nal crtamityfundS(thl:ii .sc'hool hntecetvltd "'•r1fication thattt1e1efvnd� 111r• evaHabCe}.. Summer or 011\er non--ee&damlc year ••il&nSlh wur b• met by (oxpt&i11J ___ .:F=am=_,,i,_l.,_,y'------------- " Jobi: (Musi al laa.st eqwol Items 5a and 51> abo,re.) _ 4. 750. 00 5 7. Th's sehoo{ (orif ap,11,ov�, "ot In ltsOWl'I n�m•. the----------------- Sc:i,:ccl Di.st!'.ct ��•-'wl'llcP, if ol)llratn or ______________...,.___ , School cf whlch tr is .a oart) w.as 8J;JPtovvd lor aetenda.nce by norutnmigrant's!udentt by (he Immigration •nd Natu,aJiza:iort S•rvice on _.....;4 / Q / 5 '-'3 ,,,._. ,. ,,_4 :;;L_________ ,,._. JJ.. ----------- filo numb...-_=m�1. =· :::lc.....:2=1'-" 4 =-=- .a:5CJ./-'l lce6<..4:..L)______ . Such apprCMI\ h�ncl btien ,....okecl. ,=__._(.,,, 11.RE�ARKS ___________________________________________________________ Fer ,�migration official Signature ot school offk�I authorized ub)(6);(b)(7)(C) Tille :>RM l-20A {P.EV. 4--1-76) N .I. • 1· . ·. (b)(6);(b)(7)(C) Ass.1.stant to the _Director New Student Division UNITED STATES DEPA ATMENTOFJ � l@h4rtG�(V .. ...;, '· I 1---- - 1 :9 - . Oate of l:;suanc&c (This certili=te expira• 12 months afl9r Ill& dato or issuanc1t) .. 11/2/77, n1liza1Jon Sc•rv�e " Page 1 AMY 4/777? /r Fag/?at?. garb/ff levwf ggm/gwrd I whim?. ??arbz y??a?rwd of?: gimAi/Cakm ms Amm a 51 . I <�--· REMOVAL CASE CHECKLIST Kamyar. Samimi ALIEN NAME: IBIS CHECK: l(b )(?)(E) A FILE NUMBER: POSITIVE DATE SID#': C0289976 LPR ICE STATUS: Pl CRIM CATEGORY: BOND RECOMMENDATION: NO ISAP ELIGIBLE: REVIEWING DO : ... REVIEWING SDDO: FORM NOTICE TO APPEAR ____ N_O_B_C_t._:_O____l CIS: DATE· FORM 1238805650 ---------- DATE: DATE INITIALS 1-305 1-352 1-340 1-286 NTATO EOIR IJ DECISION STIP REMOVAL 1-391 1-323 TD INFORMATION Passport in File: 1-217 TD REQUEST HQ ASSIST REINSTATEMENT 1-871 SWORN STATEMENT F.INGERPRINT COMP u YES L l NO CREDIBLE FEAR/ASYLUM LEGAL APPROVAL 1-259 W/0 APP 1-863 REFERTO lJ 1-860 ER 1-869 NEG CRED 1-869 P0S CRED Fear Claim ADMINISTRATrYE REMOVAL 1-851 1-200 1-286 l-851A Rebuttal/Appeal PRE-RELEASE CHECKS IBIS NCIC & CCIS Crim Screen LEGAL APPROVAL EXPEDITED REMOVAL OTHER APPEAL(s) 1-860 1-264 RELIEF APPS. IJ DECISION/APPEAL Stay DACA Release U/TNYlsa Other IJ DECISION RESERVE APPEAL APPEAL FILED APPEAL DECISION ALIEN (IS) (IS NOT) DETAINED AND IS READY OF REMOVAL TO 0 YES BOND INFORMATION 1--862 1-200 EXPENSE OF: 01/03/201953 Enforcement Priority .,.., --1---,�---- (b)(6);(b)(7)(C) INITIALS November 17, 2017 DOB: FINS: DATE 022 732 918 GOVERNMENT O ALIEN DISTRICT COURT 10TH CIRCUIT Date Filed 0 AIRLINE Granted Y or N Decision Date Iran DEPORTATION OFFICER REVIEW PRIOR TO REMOVAL: _________ DATE: DATE: ________ SUPERVISORY REVIEW PRIOR TO REMOVAL: --------------------------------- CONIMENTS: 0 2020-ICLl-00006 497 •- - .l . Notice to Appear, Bond, and Custody Processing Sheet U.S. Department of Homcland Scrurity A. Alicu'sNm,eKAKXAR SJ1KDCI AJCA: D.k of birth File No. 01/03/1953 Ad.dress GEO Detention Center 3130 N. fact11.11l All 022 732 918 Oak.I� St. ns (attach � sheet if ncccssaiy): See I-� 31 Da!Eofproccssing I Event Ne: l(b)(?)(E) 11/17/2017 Aurora COLORADO, 80010 £l 0 Cllaricd ""der �011212 as iuadnli'5ib!c O,vged ua&r se<:tion 237 n depcfl10NAL FACTOltS TO BE CONSlDEllED FOR. 80NWCUSTODY OFTERM.JNATION I. ls a petitiool o, aA>licalion pc:ndjng for this alia, 11r a family member" (Explain) No 2. ToQI Pml:3 � Bonded bdt>ie7 Bond btead,oci? --- ffawllllbylin,cs? _:__ tin,es? -- "-"l'IIMY -- Rdi:ued 0/Jt befon:7 Cocrtplicd willl tcrTll5 ofOIR'? __ r 3. 1'1-cs<:nt hnllh of S\lhjecl, ,pouENTITY. SP1:CIFY OATES OF MIL.STARY SERVICE, COUNTRY ANO UNIT, RANK. SERIAL NUMBER, ANO �S OF INDUCTION AND DISCHARGE. Copy of LPR card □ □ 17. IN POSSESSION OF TRAVEL. DOCUMENT OR PA88POAT AT TIME OF El'lTRY: YES NO. DESCfUIIE OOCUMEHT (S). IF SUBJECT DID NOT HAVE TRAVEl. DOCUMENT � P� ATTlME Ofl ENTRY, OR DOES HOT HAVE SUCH A DOCUMENT NOW, INDICATE WHETHER EVER OBTAINED ONE: YES NO. S'rATI; HOW, WMEN, AND WHERE rr WAS OBTAINED: WHAT KIND OIF DOCUMENT ITWAS, ANO WHAT BECAME OF rr. I 18. FATHER'S NAME PJIRVlZ Sl\KlXI PRESENT ADDRESS 19. MOniER'S MAIDEN MAME I ALEA1I SAI.ARVAKG PRESENT ADDRESS DATE OF BIR'Tli �TEOF Blffn-i I , PLACEOFBIA'Tl-l IRAN P OF&Hmi = 210. NAME. AB.ATIO�IP. AND AOORESSES OF "a.ATIVES A8ROA0 Not llpplicable 21. PREVIOUSLY ON U EXCUJDED U DEPORTED U REQUIRED TO DEPART FROM THE UNITED STATES VIA Cl'Wrl TO fC-,) 22. INDICATE WHETl-1� �• IN PRISON OR A PUBLIC INSTITVTION IN TI-IE COUNTRY OF WH!ai A NATIONAL. SU. JECT OR cmzl:N: YES NO. 1F SO, GIVE OATES AND PU'CES Not Applicabl.e 23. NAME, NATIONAUTY AND PRESENT ADDRESS OF SPOUSE, AND DATE AND PL.ACE OF MARRIAGE 24. NAMES, An.a.. AMn ADDRESSES OF ALL CHIL0REN 25; Daughter: j(b)(6);(b)(7)(C) ; AGE: 20; Daughter: Son: ¥b) (6);(b)(7)(C) f AGE: 36; See I-831 I AGE: 25. If' NONCANADIAN DEPORTABl.E 'TO CANADA. OIVE DATE ANO PORT OF ARRIVAL IN CANADA. AND NAME OF VESSEL -- Form l-'217 (Rev. 07-24-0 7) CS. O:r, SO'cet. City, P«ivicoe (S1>1,) acd Cow,i,y of Pn Nun,bcr >Dd Count:y orl.mic CO'.irmy ofCiti,< ""d No .) wt..t O Not Llftcd 0 n:.tdff..,, U/11/2017 O9:DD By See Varrat.i'Ve Stall&S Whcu Fow,d Social Security A<:omwl Name Soc:ial Sminty Numb N..,,._ �ali.,..i;ty, 11>d Add=<. ;fKz,o""'�IOlUU.ITl': IRAN \/f;\· \f7\f('_\ M 'sP=e,,too,Ll,wt1cc�N•tioGality• ...dAd4m,.,fX,,o..., I�ITY: DWf b)(6):/b) 7)/C JI,{onie> � in \;.S. Ko< in lznmedial: l'=sioo �� Ch<.lt) U.S. Ea:playr, Sea Narrative Ch�< Codr Wonts(•) Nurative S&lu y __ See 500 Weekly Narrative f.lbploycd froml TATTOOS ClUPl'LED FINGER(S), ,UGHT BAND - :Ind.el< finger Subject Heal.th Status The subject cla.ims good Current Criminal Charges hea.lth. Subject takes methadone for back pa.in (b)(6);(b)(7)(C) ..• (CONTllfUED ON :I-831) It· n-11 Distrjbuti0J1: FIU: 0ETE.NT:IO!l OFF:ICER Ir,;:(b�)(6;;;"'.);7,""(b�)(7:-:-:-)(C=)---. atc/h,-itiah) po (b)(6);(b)(7)(C) (Signanu- Received: (Subject 10d Dacvt11ci1ts) (b )(6);(b)(7)(C) Offic<� 00, November 17, 2D17 (rimt1 E::r:&miuinll! Dfct�r: fgm, 1-213 (Rev. 08/01/07) 2020-ICLl-00006 502 ,, .....1.1....i...., ' \. -· -· .. Lonunuanon .t"age Ior t·orm ________ u.-.,.., �-..:pa .. u.u.c.11.L u.1. .L.1.u.1.111:;u1uu .:,�uC1lY File Number 022 732 91 8�,.,.,.... ----�I � Event No: (b)(?)(E) Alien's Name SAM.IMI, KAMYAR ll/17/2017 - 8 use .te 11/17/2017 1227 - DEPORTABLE ALIEN :urrent Administrative Charges ll/17/2017 - 237a2Bi - DRUG CONVICTION �revious Criminal History :>n 02/08/2004, the subject was arrested for the crime of "Cocaine - Possession" which �esulted in a conviction on 03/06/2009. The subject was sentenced to O year(s), 0 month(s), 0 day(s) . Records Checked (b)(?)(E) �AND.ADDRESS OF US EMPLOYER. rmpex Auto 6490 Federal Blvd Denver, CO 80221 US rYPE OF EMPLOYMENT :,perators, Fabricators, and Laborers I\RRESTING AGENTS (b )(6);(b)(7)(C) rnNDS IN POSSESSION Jnited States Dollar 22.00 �t/Near rhornton, CO �cord of Deportable/Excludable Alien: mFORCEMENT PRIORITIES SUMMARY: -SAMIMI CLAIMS LAST ENTRY WAS AS AN Fl S1'UDENT ON OR ABOUT 04/19/1976. -SAMIMI HAS NEVER BEEN REMOVED. Signature (b )(6);(b)(7)(C) Title DO 2 ___ Qf __ Form 1-831 Continuation Page (Rev. 08/01/07) 2020-ICLl-00006 503 4 _ Pages U.S. Department of Homeland Security - ,--.. ,_ . Continuation Page for Form I-213 File Number Date 022 732 918 11/17/2017 Event No;�b� )(�?)�(E�)----..1..... -SAMIMI HAS BEEN.CONVICTED OF POSSESSION OF A CONTROLLED SUBSTANCE. -SAMIMI HAS NO GANG AFFILIATION. Alien's Name SAMIMI, KAMYAR ENCOUNTER DATA e-:,�����11..t !:a1,!,!· oo!;n was started on the SAMIMI when SAMDU 's case was assigned to me by (A) SDDO SAMIMI, Kamyar was encountered outside his home at 9001 Pozer Blvd, Thornton, CO 80229 on 11/17/2017. SAMIMI was seen leavin his residence and gettin into a silver KIA Optima with CO tags )(6);(b)(7)(C) I, IJ<.\b}(6}:(bl(7)( C) and b)(6);(b)(7)(C) roached the vehicle I b)(6);(b)(7)(C) full.y marke up as ICE officers. s was l.n erviewed by me, DO b)(6);(b)(7)(C) after identifying mysel.f as an immigration officer. SAMIMI claims to be a Cl. zen ad national of Iran by virtue of birth. SAMIMI is a Lawful Pe:r::mane.nt Resident (LE'R) but did not have his LPR card on his person. He only had a copy. Subject was told that his conviction for possession of a controlled substance violated his status and that he was under arrest by immigration for this violation. SAMIMI was then transferred to the Denver Field Office for processing. ENTRY DATA/IMMIGRATION .HISTORY SAMDll claims to have entered the United States at or near New York, NY, on or about 04/19/1976, as a F-1 student. This location is designated as a port of entry by the Attorney General or the Secretary of the Department of Homeland Security. SAMIMI clailned no other entries into the United states. ICE/CIS da tabase checks indicate that SAMIMI adjµsted his status to that of LPR IR-6, spouse of a US citizen, on 05/09/1979. applied for naturalization on 10/29/1985. on 01/09/1987, the application was denied due to lack of documents requested by the Immigration and Naturalization service. FAMILY INFORMATION SAMIMI states that his mother was once a LPR but returned to IRAN and abandoned her status. He states thc1t his father never received status. SAMIMI states that he is now divorced. SAMIMI's children are all adults and were born in the us. CRIMINAL HISTORY kb)(?)(E) SID: C02B9976 I :SAMIMI was, on 06/09/2005, convicted in the Arapahoe District Court, Centennial, CO for the offense of Possession of lg/less of a Schedule 2 Controlled Substance, to wit: cocaine, in violation of C.R.S. 18-18-405(1),(2.3) (a) (I), a Class 6 Felony, and sentenced to a te::m of 2 years defer.red sentence and 64 hours of comm.unity service. Case No. �b)(?)(E) I GANG AFFILIATION/PUBLIC SAFETY THREAT SAMIMI claims no gang membership. U.S. MILITARY HISTORY SAMIMI claims no military history. b)(? }ERSONATION CHARGE LITERAL - ----- COURT -- -- -CHARGE 01 FR.AUD-IMI?ERSONATION CRIMINAL IMPERSONATION-CAIJSE LIAB CHARGE LITERAL FELONY TYPE/LEVEL 10/03/1997 OFFENSE DATE D0l62002CR000446 noc:nT JUDICIAL CHARGE COUNT 1 DISMISSED BY DA COURT DISPOSITION 06/26/2002 DISPOSITION DATE Cycle 5 of 25 --- --- JUt.REST 02/08/2004 DATE ARRESTED C00010100 AURORA POLICE DEPARTMENT AGENCY 04-1467 ARREST NUMBER OA-CD193698 MNUt SAMIMI, RAMY.AR NNdE USED Page 2 of9 2020-ICLl-00006 513 Nov 17. 2017 11:28:30 AM CKARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CHAAGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET Printed B�(b)(6);(b)(7)(C) 01 DRUG PARAPHERNALIA-POSSESS DRUGS MARCOTIC EQUIPMENT POSS M!SDEMEANOR 02/08/2004 02 COCAINE - POSSESS DRUGS COCAINE POSSESS ARAP FELONY 02/08/2004 03 ARRESTED FOR OTHER JURISDICTION FOJ -(DUR)DOUGI.AS CO MISDEMEANOR 02/08/2004 C01B2003T 002473 =============== DATE ARRESTED AGENCY ARREST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCJ!;ET ------ COURT-----­ CAARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET JUDICIAL CHARGE COUNT COURT DISPOSITION DISPOSITION DATE SENTENCE ------ARREST-----DATEARRESTED AGENCY ARREST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET CHARGE CHARGE Ll:TERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET Clu.RGE CHARGE LITERAL TYPE/LEVEL OFFENSE OATE Cycle 6 of 25 07/20/2004 C00030000 .ARAPAHOE COUNTY SHERIFF'S OFFICE 04010347 SAMIMI, KAMYAR. 01 DANGEROUS DRUGS CONT SUBST -l?OSS SCH2 lG/LESS FELONY 02/08/2004 D0032004CR00l437 01 CONTROLLED SUBST -POSSESS SCH 2-lG FELONY 02/08/2004 D0032004CR001437 l GUILTY 03/09/2009 MUNITY SERVICE 64:00 H COMMUNITY SERVICE Cycle 7 of 25 03/19/2005 C00030200 LITTLETON POLICE DEPARTMENT 0500398B SAMIMI I KAMYAR 01 ARRESTED FOR OTHER JURISDICTION SO ARAPAHOE-POSS CONTROL SOBSTANC FELONY 03/1.9/2005 O0032004CR00l.437 02 ARRESTED FOR OTHER JURISDICTION PD CHERRY HILLS-NO PROOF INSURANC MISDEMEANOR 03/19/2005 03 ARRESTED FOR OTHER JURISDICTION SO ARAPAHOE-DEFECTIVE VEHICLE MISDEMEANOR 03/19/2005 C0702004T 208201 04 ARRESTED FOR OTHER JURISDICTION SO ARAPAHOE-UNLAWFUL CAMPING MISDEMEANOR 03/19/2005 Page 3 of9 .,IJ _ J 2020-ICLl-00006 514 _,........,_ . Noll 17, 2017 11:28:30 AM Pnnteo 8 DOCKET ------ COURT - -- -- - (b)(6);(b)(7)(C) C0702004M 201903 01 DRUG P.l\RAPBERNALIA-i?OSSESS MISDEMEANOR 02/08/2004 D0032004CR001437 2 GUILTY 06/09/2005 Cycle 8 of 25 CHARGE CHARGE LrTE.RAL TYPE/LEVEL OFFENSE DATE DOCKET JUDICIAL CHARGE COUNT COURT DISPOSITION DISE'OSITION DATE --- ---AR REST --- --DATE ARRESTED AGENCY ARREST NUMBER MNUf NAME USED CHJ>.RGE CHARGE LITERAL TYFE/LEVEL OFFENSE DATE CHARGE CllARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DRUG PARAPBERNALIA-l?OSSESS 05/21/2005 cooo10100 AURORA POLICE DEPARTMENT 05-5431 OA-CD193698 SAMIMl, KAMYAR 01 MOVING TRAFFIC VIOLATION MISDEMEANOR 05/21/2005 SPEEDING 20-24 02 FAIL TO APPEAR AURORA NPOI MJ:SD&MEANOR 05/21/2005 03 NONMOVING TRAFFIC VJ:OLATION DUC H:ISD&MEANOR 05/21/2005 ===============· Cycle 9 of 25 =======-========= ------ARREST -----06/22/2006 DATE ARRESTED C00031100 CENTENNIAL POLICE DEPARTMENT AGENCY ARREST NUMBER 06009048 NAME USED SAMIMI, KAMYAR 01 CHARGE CHARGE LI� ARRESTED FOR OTHER .JURISDICTION DENVER/OUR TYPE/LEVEL MISDEMEANOR OFFENSE DATE 06/22/2006 =============== Cycle 10 of 25 =============== ------ARREST -----PCN 016910023328 09/11/2007 DATEARRESTED CODPD0000 DENVER PD - IDENTIFICATION BUREAU AGENCY ARREST NUMBER 1557340 NAME USED SAMIMI, KAMYAR 01 CHARGE AR.Rl!!STEO FOR OTHER JURISDIC TION DOUGLAS SO DR OVE CHARGE Ll:TERAL U/RESTRAINT MISDEMEANOR 09/11/2007 =============-=== Cycle 11 of 25 =============== ------ARREST 018910008197 PCN 11/02/2007 DATE ARRESTED C00180000 DOUGLAS COUNTY SHERIFF OFFICE AGENCY 07A5589 ARREST NUMBER OA-A72568 MNUf SAMINI, KAMYAR NAME USED 01 CHARGE TRAFFIC OFFENSE DRIVING UNDER REVO.KATION CRARGE LI:TERAL MISDEMEANOR TYPE/LEVEL 11/02/2007 OFFENSE DATE TYPE/LEVEL OFFENSE DATE Page 4 of9 : .L• ,. • JI) 2020-ICLl-00006 515 ,_I, I I C Printed B1(b)(6);(b)(7)( ) Nov 17, 201711:28:30 AM CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE 02 TRAFFIC OFFENSE FAILURE TO PROVIDE PROOF OF ms MISDEMEANOR 10/30/2007 =============== Cycle 1.2 o.f 25 ------.ARREST-----PCN 034010000360 11/21/2007 DATE ARRESTED C00030500 CHERRY BILLS VILLAGE POLICE DEPARTMENT AGENCY 11939 ARREST NUMBER NAME USED SAMIMr, RAMYAR CHAR.GE CHARGE LITERAL TYPE/LEVEL ------ARREST-----PCN DATE ARRESTED AGENCY .ARREST NUMBER MNOt NAME USED CHARGE CHARGE LITERAL OFFENSE DATE DOCKET - ----ARRE ST-----PCN DATE ARRESTED AGENCY ARREST NtlMBER NAME USED Cl TRAFFIC OFFENSE DRIVTNG UNDER RESTRAJ:NT MISDEMEANOR Cycle 13 of 25 014C20183945 01/07/2008 C00030400 GLENDALE POLICE DEPARTMENT 346340107 2008-0077 SAMIMI,KAMYAR 01 ARRESTED FOR OTHER .JURl:SDICTION 01/07/200B D0032004CR001437 Cycle 1.4 of 25 SO ARAPAHOE FTA DRUGS 003920013002 06/18/2008 C00030000 ARAPAHOE COUNTY SHERUT' S OFFICE 08008369 SAMIMI , �AR 01 FAIL TO APPEAR MISDEMEANOR 06/18/200B C0712007T 106520 =============== Cycle 15 of 25 ------ARREST -----016930037928 PCN 12/03/2008 DATE ARRESTED CODPDOOOO DENVER PO - IDENTIFICATION BUREAU AGENCY 1615537 ARREST NUMBER SAMIMI, �AR NAME USED 01 CHARGE ARRESTED FOR OTHER JURISDICTION SO ARAPAHOE DANGEROUS CHARGE LITERAL DRUGS FELONY TYPE/LEVEL 12/03/2008 OFFENSE DATE D0032004CR001437 DOCKET 02 CHARGE ARRESTED FOR OTHER JURISDICTION SO ARAPAHOE CARELESS CHARGE LITERAL DRIVING MISDEMEANOR TYPE/LEVEL 12/03/2008 OFFENSE DATE C0712008T 103423 DOCKET =============== Cycle 16 of 25 =============== ------ ARREST 016930045215 PCN 04/27/2009 DATE ARRESTED CODPDOOOO DENVER PD- IDENTIFICATION BUREAU AGENCY 1632713 ARREST NUMBER CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET Page 5 of 9 2020-ICLl-00006 516 , .,,,_ _ II. Nov 17, 2017 11:28:30 AM NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DAXE CHARGE CBARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE CHARGE CHARGE LITERAL Printed B�(b)(6);(b)(7)(C) SAMIMI, K1.MYAR 01 DAW.GE PROPERTY - FRIVATE MISDEMEANOR 04/27/2009 02 DISTURBING THE PEACE MISDEMEANOR 04/27/2009 03 ASSAULT MISDEMEANOR 04/27/2009 04 FAIL TO APPEAR DRIVING UNDER RESTRAINT MISDEMEANOR 04/27/2009 05 ARRESTED FOR OTHER .JURISDICTION ARAPAHOE SO/CARELESS DRIVING TYPE/LEVEL MISDEMEltNOR OFFENSE DATE 04/27/2009 DOCKET C0712008'1' 103423 =============== Cycle 17 of 25 =============== ------ARRE ST-----PCN 016910061312 DATE ARRESTED 08/21/2009 CODPDOOOO DENVER PD - IDENTIFICATION BUREAU AGENCY ARREST NUMBER 1646909 NAME USED SAMIM:r, KAMYAR CHARGE 01 C� LITERAL FAIL TO APPEAR DESTRUCTION OF PRIVATE PROPERTY TYPE/LEVEL MISDEMEANOR OFFENSE DATE 08/21/2009 CHARGE 02 CHARGE LITERAL ARRESTED FOR OTHER JURISDICTION ARAPAHOE COUNTY-TRF TYPE/LEVEL MISDEMEANOR OFFENSE DA1'E 08/21/2009 C0712008T 103423 DOCKET Cycle 18 of 25 =============== ------ARREST ------ PCN DATE ARRESTED AGENCY ARP.EST NUMBER NAME USED CHARGE CHAR.GE LITERAL TYPE/LEVEL 016010010297 12/29/2009 C00010400 THORNTON POLICE DEPARTMENT 09009463 SAMIMI, 11:AMYAR 01 THEFT MISDEMEANOR =============== Cycle 19 of 25 =====-=========== ------AR.REST-- ---016930061818 PCN 04/10/2010 DATE ARRESTED CODPDOOOO DENVER PD - IDENTIFICATION BUREAU AGENCY 10-026206 AAREST NUMBER SJUfiMI, :AAMYAR NAME USED 01 CHARGE SHOPLIFTING CHARGE LITERAL 02 CHARGE TRESPASSING CHARGE LITERAL 03 CHARGE TRAFFIC OFFENSE NO INS'ORJUJCE-OWNER CSARGE LITERAL Cycle 20 of 25 Page 6 of9 2020-ICLl-00006 517 • .. _JI J. Nov 17, 201711:28:30AM ------ARREST -----PCN DATE ARRESTED AGENCY ARREST NUMBER NAME OSED CHARGE CHAR.GE LITERAL OFFENSE DATE DOCKET Printed Byi(b)(6);(b)(7)(C) 003920037680 12/15/2010 C00030200 LITTLETON POLICE DEPARTMENT 10016569 SAMIMI,KAMYAR 01 ARRESTED FOR OTHER JURISDICTION THORNTON FAIL TO PAY FINE 12/15/2010 WM0\24550 Cycle 21 of 25 =============== ------ARREST ------ PCN DATE ARRESTED AGENCY ARREST NUMBER � USED CHARGE CHARGE LITERAL TYPE/LEVEL DOCKET 016930086813 02/10/2011 CODPDOOOO DENVER PD - IDENTIFICATION BUREAU 11-057B75 SAMJMI,KAMYAR 01 TRAFFIC OFFENSE DRIVING UNDER RESTRAINT MISDEMEANOR B924314 Cycle 22 of 25 =============== ------ARREST-----PCN OA'l'E ARRESTED AGENCY ARR.EST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL D�T PCN DATE ARRESTED AGENC Y ARRE ST NUMBER MNU# NJ>.ME USED CRAR.GE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET ------COURT-----­ CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCl'CET JUDICIAL CHARGE COUNT COORT DISPOSITION CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET JUDICIAL CHARGE COONT COURT DISPOSITION CllARGE CHARGE LITERAL =============== 001910037692 12/30/2015 C00010000 ADAMS COUNTY SHERIFF'S OFFICE 11CN15012630 SAMIMI,KAMYAR 01 ARRESTED FOR OTHER JURISDICTION MISDEMEANOR AM213503A Cycle 23 of 25 =============== ------AR REST------ =============== AR.,n,I)A PD/�- THEFT =============�= 03091000097871 09/21/2016 C00300100 ARVJWA POLICE DEPARTMENT 1616B06 OA- P01103087 ·SAMIMI,KAMYAR 01 ARRESTED FOR OTHER .roR.ISDICTION MISDEMEANOR 09/21/2016 C0012016T 000165 ADAMS SO FTA DUR 01 TRAFFrC OFFENSE FAILURE TO DISPLAY PROOF OF INSURANCE TRAFFrc 12/30/2015 C0012016T 000165 1 DISMISSED BY DA 02 TRAFFIC OFFENSE VJL LAMP VIOUTION TRAFFIC 12/30/2015 C0012016T 000165 2 DISMISSED BY DA 03 TRAFFIC OFFENSE DRIVING ONDER RESTRAINT Page 7 of 9 2020-ICLl-00006 518 Nov 17, 2017 11:28:30 AM TYPE/LEVEL OFFENSE DATE DOCKET JUDICIAL CHARGE COUNT COURT DISPOSITION SENTENCE ------ARREST -----PCN DATE ARRESTED AGENCY ARREST NUMBER NAME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET ------ARRE ST -----­ Printed By: (b)(6);(b)(7)(C) MISDEMEANOR 12/30/2015 C0012016T .00016S 3 GUILTY 7 00 D JAIL 7 00 D CRTS 7 00 D JAIL 7 00 D CRTS Cycle 24 of 25 ================== 016010031594 07 /27/201 7· C00010400 THORNTON POLICE DEPARTMENT 201710444A SAMIMI , 10\MYAR 01 ARRESTED FOR OTHER JORISDICTI:ON SO ADAMS MISDEMEANOR 07/27/2017 C0012016T 000165 Cycle 25 of 25 PCN DATE ARRESTED AGENCY ARREST NUMBER IO.ME USED CHARGE CHARGE LITERAL TYPE/LEVEL OFFENSE DATE DOCKET 001910047608 10/14/2017 COOOlOOOO .ADAMS COUNTY SHERIFF'S OFFICE 11CN17010790 SAMIMt,KAMYAR 01 FAIL TO APPEAR FTA MISDEMEANOR 10/14/2017 C0012016T 000165 .ADDRESSES: ADDI:TIONAL 07/01/1987 290 W GRAND AVE #202A 11/07/1996 10/17/1999 12/01/2001 02/08/2004 07/20/2004 03/19/2005 09/11/2007 06/18/2008 12/03/2008 04/27/2009 08/21/2009 12/29/2009 12/15/2010 12/30/2015 09/21/2016 172 KENTON ST #112 DENVER co 7630 E WARREN CR 7-108 DENVER co 5630 E WARREN CIRCLE 7108 DENVER co 3640 E MALLARD DR LITTLETON CO 3640 E MALLARD DR HIGHLANDS Rl\NCH CO 3640 MAI.LARO DR LITTLETON CO 3640 E to.LI.ARD HIGHLMIDS RANCH CO 7321 S QUEBEC CT CENTENNIAL CO 7123 S QUEBEC DENVER CO 7123 S QUEBEC ST CENTENNIAL CO 3640 E MALLARD DR DENVER CO 3640 E MALLARD DR HIGHLANDS RANCH, 4470 E JEWELL AV DENVER CO 80222 3640 E MALLARD DR HIGHLANDS RANCH CO 80126 6190 FEDERAL BLVD Page 8of9 2020-ICLl-00006 519 ,,-._, Nov 17. 2017 11 :28:30 AM ,,-...._ Printed By: DENVER �b)(5);(b)(7)(C) co 80222 11/07/1996 SALES 10/17/1999 MANAGER 12/ 01/2001 .MECHANIC 02/08/2004 CAR SALESMP.N 07/20/2004 AUTO TECH 11/02/2007 AUTO D£ALER 01/07/2008 OWNER 09/21/2016 UNEMPLOYED OCCUPATIONS: *** THE ABOVE INFOIU-!ATION IS PROVIDED STRICTLY FOR AND IS LlMITED *** TO THE OFFICIAL USE OF CRIMINAL JUSTICE AGENCIES. *** FALSIFYING OR ALTERING THIS RECORD WITH THE INTENT TO MISREPRESENT THE •u CONTEN'tS OF THE RECORD IS PROHIBITED BY LAW, AND MAY BE PUNISHABLE AS *** A FELONY WBEN DONE WITH THE INTENT TO INJURE OR DEFRAUD ANY PERSON. •u *** *U *** ••• *** *** THIS RECORD MAY NOT SHOW ALL ARRESTS FOR THIS INDIVIDUAL; •u HOWEVER, ALL INFOR19.TION PROVIDED TO THE CBI IS INCL'CDEO IN THIS RECORD. *** ------- 1 1/17/ 2017 1 1:2 BMT ------END OF RECORD MIU 8416932 IN: CCHX 15823 AT 11:28 17NOV17 OUT: IM1 3 AT 11:28 17NOV17 Page9 of9 2020-ICLl-00006 520 . . : J.I • I ,,,....___ Nov 17, 2017 11 :28: 17 AM Printed By: 44968 from: IM1 Received Time: Summary; ·V.iew Message Details 1::28:05 �1-17-17 QR: l(b)(7 )(E) I PUR=C Source ORI: 11/17/2017 11:28 Message received from NLET CR J(b)(7)(E) 11:2B ll/17/2017 29228 11: 28 11/17/2017 11014 fb)(7)(E) L-----� •MRIB416902 TXT This rap sheet was produced in response to the following request: Request Id Purpose Code Attention MRI8416902 C RAMIREZ The info.rmation in this rap sheet is subject to the fellowing caveats: (US; 2017-11-17) (US; 2017-11-17) (US; 2017-11-17) This record is based only on the fb)(7)(E) �---l in your I @� request-UCN: Because additions or deletions may be made at any time, a new copy should he requested when needed for subsequent use. (US; 2017-11-17) All arrest entries contained in this FBI record are based on fingerprint COJDparisons and pertain to the same individual. (US; 2017-11-17) 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; 2�17-11-17) Subject Name (s) SAMIMI, KAMYAR SAMIMI, KAMI SAMINI, KAMYAR (AKA) (AltA) SAMIMI, KAMYAR NM (AKA) Subject Description State Id Number C0289976 (CO) So i b)(6);(b)(7)(C) Page 1 of2 2020-ICLl-00006 521 . . . _LI , I Nov17,201711:28:17AM Miscellaneou )(7)(E) Printed By: 44968 from: IM1 Numbers AR sex Male Race White Height 5'08" Weight 145 Hair Color Black Date of Birth 1953-01-03 1953-01-30 Eye Color Brown fL�-)(7_�__r_i_n_t_P,_•_*' ___ � PC) Scars, Marks, and Tattoos Description, Comments, and Images Code , MISSING FINGER(S) ON RIGHT HANO MJ:SS R FGR Place of Birth Iran F Ci tiz:enship United States Iran Fingerprint Images Earliest Event Date Cycle 1 2017-11-17 Arrest Date 2017-11-17 Arrest Case Number 177226850 Arresting Agency �CE/ERO DEWER FL:) 0 Rb)(7)(E) Subject's Name SAMIMI,KAMYAR 1. Charge Charge Literal DRUG CONVICTION Severity Unknown Charge 2 Charge Li.tera.l DEP0RTABLE ALIEN Severity Unknown ••••••••••••••••••••••••• INDEX OF AGENCIES •••••••••••••••••••••••••• Agency Agency Email Address Address l __ ICE/ERO DENVER F!.D 0;1��-l�_>(_E_ CENTENNIAL, CO 80111 •*•END OF RECORD*•* MRI 8416923 IN; NL:1 1�945 AT :1:28 17NOVl7 OUT: :Ml 2 AT 11:28 l?�ov:7 Page 2 of 2 . . - 1. :I. - . 2020-ICLl-00006 522 Page 1 of 12 2004CR1437 - Arapahoe Cmi.!lt.X Date Printed: 12/13/2016 People Of The State Of Colorado Vs. Samimi, Kamyar - 2004CR1437 - Arapahoe County Summary ...J "( Case#: 2004CR1437 (District) Location: Arapahoe County Date Filed: 2004-06-08 Date Case Closed: 2009-03- Date of Speedy Trial: N/A Case Type: Drugs Appealed: Y E-Filed: N Judge or Magistrate: Kurt A Division: 204 Bar Number: 10537 Case Status: Closed; 06 Horton Alternate Judge or Magistrate: Michael James Spear .:: :z w a it .c: 0 u Bar Number: 19986 Related Cases: N/A u Participants Party Type: Defendant Person Status: Not Applicable Name: Sarnimi, Kamyar Addresses & Phone Numbers Attorneys Birthdate: 1953-01-03 Gender: M Race: W Drivers License: CO Historical Address 3640 Mallard Dr Littleton co 80126 �b)(6);(b )(7)(C) I SSN: l(b)(6);(b)(7)(C) State.1u: 289976 I Historical Address 3640 E Mallard Dr Littleton co 80126 Active Address 7123 S Quebec Denver CO 80231 Home : (720) 6202471 Party Type: The People of the State of co ...J I.U Attorney Role: Private Attorney b)(5);(b)(7)(C) Attornev Name: i< l(b)(6);(b)(7)(C) I Attorney Bar#: 1741 Primary Attorney: Yes Attorney Role: Deputy Public Defender Attorney Name: fb)(6);(b)(7)(C) Attorney Bar#: 37870 Primary Attorney: Yes 9 l.l. I�u _, ;z: � � 0 u Person Status: Not Applicable .:: z UJ Name: The People Of The State Addresses & Phone Numbers Attorneys Q Of Colorado, 0 Sirthdate: Gender: Race: Drivers License: StatelD: l �--------------------------------------� .... .: 'C( ...J :5 � i Arresting Agency a i o Charges / Dispositions 8 Arresting Agency: Aurora Police Dept Ticket/Summons Number: 8 Arrest Date: Arrest Time: Arrest Number: Case Number: 04...I 2020-ICLl-00006 523 12/13/2016 Page 2 of 12 2004CR1437 -Arapahoe Cou!lty ...... i=: :z: w a u Final Disposition on Charges I 16937 Char-ge Number: 1 I Status: Main Charge Charge � oritrolled Subst-possess Sch 2-1g/�es� . . Class: F6 (Class 6 Felony) BAC: 0.000 Offense Date From: 2004-02-08 Offense Time: 09:42 PM Offense Date To: Statute: 18-18-405(1 ), (2.3)(a) (I) Plea Date: 2005-06-09 Plea: Plea of Guilty Disposition: �l�, Disposition Date: 2009-03-09 Disposition Date: 2005-06-09 Disposition: Deferred Sentence Sentence Date: ,Ot 9� Sentence Type: Sentence by Court b-'"J-"06 rf!rred J 2.00 Year(s) Revoked No Consecutive / Concurrent sentences. ____ence· · Alcohol Eval Fee 181.00 Dollar Amount Community 64.00 Hour(s) Service Request for Time 25.00 Dollar to Pay Amount Court Costs - T, 35.00 Dollar M,CR Amount VAST min for off 162.50 Dollar after 5/1/03 Amount Victim 125.00 Dollar Compensation Amount Fund Offender 128.00 Dollar Identification Amount Fund ··-· -- Comments: FELONY CONVICTION ENTERS. PROBATION IS TERMINATED UNSUCCESSFULLY. NO FURTHER JAIL IMPOSED. COSTS AND FEES CONVERTED TO CIVIL JUDGMENT. CASE IS CLOSED./DB Sentence Date: 2005- Sentence Type: Sentence by Court 06-09 Deferred 2.00Year(s) Sentence Alcohol Eval Fee 181.00 Dollar Amount Community 64.00 Hour(s) Service Request for Time 25.00 Dollar to Pay Amount Court Costs - T, 35.00 Dollar Amount M,CR VAST min for off 162.50 Dollar after 5/1/03 Amount Victim 125.00 Dollar Compensation Amount Fund Charge Number: 2 Ll(b-)(?- )(-E) . ' ISentence Status: Active I z LIJ 0 0 0 Sentence Status: Vold No Consecutive / Concurrent sentences. Comments: 2 YEARS DEFERRED JUDGMENT ON COUNT 1. DRUG & ALCOHOL EVAL/TREATMENT. 64 HOURS PUBLIC SERVICE. DEFT TO PAY COURT COSTS. FINE OF $100.00 IMPOSED ON COUNT 2. DEFT TO REPORT IMMEDIATELY TO THE PROBATION DEPT. /SSS Charge: Drug Paraphernalia-possess I ]Status: Main Charge LL z 0 0 c.c..=.---------�l2/13/2016 � _____________.L.U.,<.l.L:JL.1...<.LJ.:U.1.LU.U .......... 2020-ICI 1-QQQQS 524 Page 3 of 12 2004CR1437 -Arapahoe Cou� Offense Date From: Offense Date To: Offense Time: 09:42 PM Class: PO2 (Class 2 BAC: 0.000 Statute: 18-18-428(1) 2004-02-08 Petty Offense) Plea Date: 2005-06-09 Plea: Plea of Guilty Disposition: Guilty Disposition Date: 2005-06-09 Sentence Date: 2009- Sentence Type: Sentence by Court Sentence Status: Active 03-06 Court Costs - T, M,CR 100.00 Dollar Amount No Consecutive / Concurrent sentences. No Comments Sentence Status: Void Sentence Date: 2005- Sentence Type: Sentence by Court 06-09 Court Costs - T, M,CR 100.00 Dollar Amount No Consecutive / Concurrent sentences. No Comments Hearings/Trials Q ..J Vacated Kurt A Horton (10537) 201 Review Vacated Christine Noelle Chauche (20751) 06:00 CL'< Review NOTE: EXHIBIT REVIEW Clerk Of Court (900001) Clerk Of Court (900001) 201807-25 AM 06:00 201 201408-29 AM 06:00 02-28 AM 200905-25 AM 06:00 CLX Review NOTE: EXHIBIT REVIEW 200903-06 01:30 PM 204 Hrg-Revocation of Probation Hearing Held Carlos A Samour JR. (19955) 200902-13 AM 10:00 204 Hrg-Revocation of Probation Hearing Held Carlos A Samour JR. (19955) 200901-05 AM 10:00 204 Hrg-Revocation of Probation Continued by John Lawrence Parties Wheeler (12975) 200812-08 AM 0 2008- u Review NOTE: WARRANT Room# Type/Note i:i: 2012- :z LI.I Judge/Bar Number Time Q 2:: 0 (J Status Date 08-01 2008- ' 1/26/2017 . Search » Denver County CourtDenver County Court ,,-.__ 04/16/2010 104/16/2010 2 Page 2 of 3 o- THEFT SEMINAR 74.69 RESTITUTION ORDERED Fines and Costs Information Description - - �-----�-- ----- -·-- ---- Imposed COMPLETED DOLLARS 16 COMM SERV ORDERED 04/08/2011 HOURS -·-----·---- Suspended 07/08/2010 - · · · · - · ·· · - · · · --····-··-··----·-· CCWP/CTS J . Paid Duel ! RESTITUTION 74.69 0 00 0.00 0.00 74.69 SUPERVISION FEE 75.00 0.00 0.00 0.00 75.00 ASSET RECOVERY FEE 80.00 0.00 0.00 0 00 GENERAL SESSIONS COURT COST 26.00 0.00 0.00 0 00 80.00 I i 26.00 WARRANT FEE (GS) 50.00 0.00 0.00 0.00 50.00 USEFUL PUBLIC SERVICE 25.00 0.00 0.00 0.00 25.00 VAS (SURCHARGE) 20.00 0 00 0.00 0.00 20.00 BOND FEE 60.00 0.00 0 00 60.00 0.00 $410.69 $0.00 $0.00 $60.00 $350.69 Totals: I I Action Information ,□ate Action 04/15/2011 8:30 AM PAPER REVIEW 04/08/2011 8 30 AM 03/04/2011 8:30 AM 03/01/2011 8:30 AM Judicial Officer Crtrm Dispo 3G VACATE COURT DATE REVOCATION HEARING 3G PETITION WITHDRAWN REVOCATION HEARING 3G VACATE COURT DATE MISCELLANEOUS HEARING 3G SET NEW COURT DATE 145z REFER TO COLL NO PAYMENT PLAN FINE/COSTS TOTAL 3G FINES DUE BOND RETURN DATE 3G SET NEW COURT DATE (b)(6);(b)(7)(C) Amo-u� I 01/28/2011 10:30 INTEGRAL REFERRAL PM 01/28/2011 1 :00 AM 01/03/2011 2:49 !pM 12/17/2010 8:30 AM 12/17/2010 8:30 AM COLLECTION REVIEW COLLECTION LETTER SENT 11/21/2010 4:50 PM WARRANT CANCELLATION ORDERED 09/10/2010 8:30 AM REVOCATION HEARING 3G FAILED TO APPEAR (FTA) FAIL TO APPEAR WARRANT ORDERED 3G WARRANT ISSUED REVOCATION MOTION 3G FINE/COSTS TOTAL 3G FINE OR SOE REVISED PAPER REVIEW 3G SET NEW COURT DATE 09/10/2010 8:30 AM 07/08/2010 9:52 AM 07/08/2010 9:00 AM 07/08/2010 9:00 AM r)LAINT AA"l> INFORMATION CHARGES COL'NT 1: POSSESSION OF A CONTROLLED SUBSTANCE - SCHEDULE II-1 GRAM OR LESS, 18-18-405(1),(2.3)(a)(I) (F6) [82011] Summons Requested. AURORA POLICE DEPARTMEm, Arapahoe County, Colorado. Summons to issue this ;;)..Q� day of � ?' day of �� , 2-0 -o7, and returnable on the , � , at�:.3.ca.m. Defendant ordered booked and released. �Ct_ Judge � Judge Original 2020-ICLl-00006 539 5-- People v. KAMYAR SA.MIMI OFFICE OF THE DISTRICT ATTORNEY EIGHTEENTH JUDICIAL DISTRICT STATE OF COLORADO NOTICE THE DEFE�TlANT A.'® HIS/HER ATTOM'EY IN nns ACTION TO: 1'.?ow,\.) _ _ .,,.,J.J.... I ;1 ,,__ c:\ I I '-- "J \ilCTIM APPROVAL: • '-J , ('.,.._,,c,; DEPUfY DISTRICT ATTORNEY: �a� \2). � Reg.No. c:211/.33 Date: lR,_ US:: -9 BY TIIE COURtfJ l \1�,Gcfr= YES _ _ ".'-iO _ _ CONTACTED BY 1 HANSEN BROS. PRINTING aoe.-1� .I 202D·ICLl·00006 542 y_�·: I,: ; ,- - .,· � - - 1 ,-, ·--.!Jis':.rict Court, Arapan'.�i..:" ...... aunty, Sta':.e of ColoraG_ Case#:D00320C4CR001437 Div/Room: 207 J""JDGMENT OF CONVICTION, SENTENCE Original The People of Colorado vs SAMIMI, KAMYAR DOB 1/03/1953 SID 289976 The DefeLdant was se�tenced on: 6/09/2005 ?eop�e represented by... : ENGEL, PATRYC3 S DefeLda�t represented by: DEVITO, STEVEN HENRY UPON DEFE�"DANT 1 S CO�VICTION th�s date of: 6/09/2005 The defendant pled guilty to: Count # 1 Charge: Controlled subst-Possess sch 2-:g/less Class: F6 C.R.S # 18-18-405(1), (2.3) (a) (I) Da':e of o.:fense(s): 2/08/2004 to 2/08/2004 Da'=e of plea(s): Count # 2 C�arge: :::Jr:..:.g Paraphernalia-Possess Class: P02 C.R.S # 18-18-428(1) Date of offense(s): 2/08/2004 to 2/08/2004 Date of plea(s): 6/09/2005 6/09/2005 IT IS THE JUDGMENT/SfilITENCE OF THIS COURT that the defendaLt be sentehced to De:erred se�te�ce 2.00 YEARS COUN"T l 2 YEARS DEFERRED JUDGM3NT ON COUNT 1. DRUG & ALCOHOL EVAL/TREATMENT. 64 HOU�S PU3LIC SERVICE. DEFT TO PAY COURT COSTS. FINE OF $100.00 IMPOSED ON COUN"T 2. /SSS DEFT TO RE?ORT IMMEDIA':i:'ELY TO THE PROBATION DEPT. $ Assessed 628.50 $ Balance 62 8. 5 0 ADDITIONAL REQUIREMENTS 64.00 hours of Useful Public Service Complete JUDGMENT OF CONVICTION IS NOW ENTERED, IT IS FURTIIER ORDERED OR RECOMMENDED: JUDGE/MAGISTRATE�"{Vl__;_,J_y� ckr VINCENT RENALDA ITE CERTIFICATE OF SHERIFF I CERTIFY THAT I EXECUT3D THIS ORDER AS DIRECTED SHERIFF DATE._ _ _ _ _ _ _ _ - BY DEPU�T�Y�----- - - - - - - - '"' n ;-- �.! '" :� 2020-ICLl-00006 543 I' I I -:; DISTRICT COURT, ARAPAHOE COUNTY, COLORADO 7325 South Potomac Street, Centennial, Colorado 80112 Filed in �h e Div. Plaintiff(s): THE PEOPLE OF TI-IE STATE OF COLORADO, �½W'L Defendant(s): S:At\: I., MARS· 2009 District o urt Ar.:ipahoe Coi n ty. Cola. f'L( A COURT USE ONLY A Case No.: � CR f'-{?1- Div.:�� JUDGMENT This Matter comes before the Court for entry of judgment upon the request of the parties, and the Court being advised in the premises hereby enters judgment for The People of the State of Colorado -----------,.--------------------- and against the Defendant k Pc�� �u..,. � for the unpaid financial obligation remaining in this case from the Court's previous orders, in the principal amount of$ _f_�.,...- _L-·.....,,.,,,_\_�------- Post-judgment interest shall accrue as provided by law. Done this _0_':'". 7 L --_ _ -;z:: - r' I �:-�c�� HANSEN BROS. ?RINTING • UThETON, COLORADO 2020-ICLl-00006 544 . • .I., .• . I I I /G IMPORTANT INFORMATION ABOUT PROTECTION ORDERS THIS ORDER IS IN EFFECT UNTIL THE DISPOSITION OF THIS ACTION, OR, IN THE CASE OF AN APPEAL, UNTIL THE DISPOSITION OF THE APPEAL. This Order is accorded full faith and credit and shall be enforced in every civil or criminal court of the United States, an Indian tribe, or a United States territory pursuant to 18 U.S.C. Sec. 2265. The issuing court has jurisdiction over the parties and subject matter. The Defendant has been given reasonable notice and opportunity to be heard. NOTICE TO DEFENDANT: ✓ A knowing violation of a Protection Order is a crime under §18•6·803.5, C.R.S. A violation may subject you· to fines of up to $5,000.00 and up to 18 months in jail. A violation will also constitute contempt of court. ✓ You may be arrested without notice if a law enforcement officer has probable cause to believe that you have knowingly violated this Order. ✓ If you violate this Order thinking that a victim or witness has given you permission, you are wrong, and can be arrested and prosecuted. ✓ The terms of this Order cannot be changed by agreement of the victim(s) or witness(es). Only the Court can change this Order. ✓ You may apply at any time for the modification or dismissal of this Protection Order. NOTICE TO LAW ENFORCEMENT OFFICIALS: ✓ You shall use every reasonable means to enforce this Protection Order. ✓ You shall arrest, or, if an arrest would be impractical under the circumstances, seek a warrant for the arrest of the restrained person when you have information amounting to probable cause that the restrained person has violated or attempted to violate any provision of this Order and the resP-.11ined person has been properly served with a copy of this Order or llas received actual notice of the existence of this Order. ✓ You shall enfo rce this Order even if there is no record of it in the Protection Order Central Registry. You shall t ake the restrained person to the nearest jail or detention facility utilized by your agency. You are authorized to use every reasonable effort to protect the alleged victim and the alleged victim's children to prevent further violence. You may transport, or arrange transportation for, the alleged victim and/or alleged victim's children to shelter. NOTICE TO PROTECTED PERSON: ✓ You may request the prosecuting attorney to initiate contempt proceedings against re strained person. JDF 440 Rl/04 MANDATORY PROTECTION ORDER PURSUAt','T TO� 1&.J-1001, C.RS. (Pa�• 2 ar �, 2020-ICLl-00006 545 - Sep/22120�6 12:43:12 AM ?ECEIVED 3036521849 09/22/2016 0a:43 JCSO Sheriff 3D3-271-5561 1/1 c_ v f'v' VI L' JIU /...., ------JEFFERS­ COUN RIF� SAMIMl,KAMYA.R DOB .Q1LQMJ SSN: (b)(6);(b)(7)(C) HGT: BKG.# � WGT; OATE OF ARREST 150 EYES: .!IBQ 0<1121 {201 B � - i -.,1 IT' ,"> � � (', y. 6-l E,. e,� ,-El, - C, .S f'�/'... FG.:, OIV'! tV .f j t:f l"(C).,(,,, .;VEGA A� fi../Jr1-1;:1 Tc, tJ u /1- I' lfl Ou/f {. M/!�/fTe fl r--A ff'...to/1.. ltfl-f\J:S T� ..,....,1-r1�� /!..t:<"--":J �£d'¥­ � 0:.:.:1. 7/;J_••ifi. r}.../::..1//�¥:,- � HAIR: fillS_ TIME OF ARREST: ll11 ALIAS: FTA DUR PENDING CHARSES 5 REQUESTOR'S NAME: (b)( );(b)( ?)(C) DRO DUTY DESK RESiDNSE: 1 5 CALL BAC:K#: fb)( );(b)(?)(C) 1Ja fWt.-:o I FAX# �03-271-5561 DATE: ·L ft? rL - f(L-Lti(L- 1 H� r.1, ,..r,' ..s I i K..__:01t--t.,,,, �uCS oA__hEILE.7'A/LPR Priority Level: Case Country of Donald Loveless Officer: Citizenshi : Samimi, Kamyar '.'lame: Case l'"umber: l(b)(7)(E) Height: 5' 8" Scars,Marks,and/or Tattoos: b)(7)(E) Missing Right Finger b)(6);(b)(7)(C) Vehicles: (b)(7)(E) 1) 2) 3 Address: City: 150 Weight: SID #'s P2b Iran AKA: Male Bro Eye Color: Jefferson County Sheriff Lead Type: KS TEP: N Age: 64 A022732918 A Number: Samini, Kamyar Date of Birth: Hair Color: Blk 1/3/1953 Complexion: Med C0289976 Issuing State: co SS.:-.1: Spouse/Children (Name & Status): L"nknown ... CRIM.ll'iAL HISTORY (.MOST EGREGIOUS) ... Controlled Subs Poss (F6) ... TARGET ADDRESS ... 9001 State: Telephone Numbers: Secondary Addresses: Zip: co J-o ;;:; '1 Employer & Address: LOCAL LAW ENFORCEMENT WILL BE NOTIFIED PRIOR TO COMMENCEMENT OF OPERATION Agency: ... LAW ENFORCEMEl\T l\'OTIFICA TIO.:-.1 ... Name: Denver Police Department Address: ... EMERGE�CY MEDICAL SERVICES ... Denver Health Medical Center Telephone: Telephone: Name: Agency: Name: I Dispatch I Telephone: rb)(6);(b)(7)(C) 777 Bannock St, Denver, CO 80204 I A\A{ EJ\IEQRCEMEI\IJ SEI\ISIIIVE FOB OFFICIAi..; !SE 01\ll..Y 2020-ICLl-00006 547 l(b)(6);(b)(7)(C) I I h. Operation Risk Assessment TARGET INFOR"\IATIOI"\ (Check all that apply) Flight/ Escape Risk History of Violence/ Conviction Weapons Charges or Conviction felony Charges or Conviction X Substance related issues or Terrorist/Gang Activity Conviction or Conviction X TARGET TOTAL 2 LOCATION Il'iFORMATION (Check all that apply) >6 Adults/teens :\1:ultiple Structures High Crime Area >3000SqFt Dangerous Animals Children LOCATIOI\' TOTAL Consider alternative apprehension methods below if a total of five boxes or more are checked. Consider alternative apprehension methods anytime a red box is checked. ALTER'liATE APPREHENSION METHODS • • • • • Contact ERO Special Response Team Tactical Supervisor Serve warrant at a different time or location Conduct vehicle stop Request additional manpower from other ERO Units Request assistance from another agency Date(s) of Operation: Time of Operation: APPROVAL Preparing Officer Signature: r)(6);(b)(7)(C) Justification for Operations conducted Out.side normal hours of operation (If Required): I (b )(6);(b)(7)(C) If Required): Name of Consent Provider: CONSE!li'T Scope of Consent: Time Consent Given: Witness to Consent: Language Csed by Consent Provider: Time if Consent Withdrawn: Consent Obtained by: Method in which consent was obtained (e.g. in person, via translator): RESULTS Date: Location: Additional Information: I A\/\{ FNFORCE�aEI\IT Sli=�ISITIV15. P:OROFFICIAL USE ONLY 2020-ICLl-00006 548 ·----- -- r-. Online Detainee Locator System PRNACYNOTICE * * * * This notice is not applicable to detainees under the age of 18. * * ** U.S. Immigration and Customs Enforcement (ICE) v.ill include limited personal information about you in the Online Detainee Locator System, a publicly searchable Internet database. While any person can use the Detainee Locator, it is intended to assist family members, friends , and " le gal representatives in locating persons who are .in ICE custody. The following personal information will be made available in the Detainee Locator: your full name, your year of birth, your country of birth, your custodial status ("in custody" or"not in custody''), and your current detention fac.ility. The Detainee Locator also provides the address, phone number,and website for your current detention facility, and contact information for the· ICE Enforcement and Removal Operations (ERO) office that is handling your immigration case. Peo J)Ie usin g the Detainee Locator may search for you by entering your country of birth, and "either your Alien Registration Number (A-N_umber) Q!your first and last name. To search the Detainee Locator by name, the name entered must be an exact match to your ruune in the Detainee Locator. It is important that you tell relatives your two names'that appear in the locator system. " " 0 0 -'0 r 6 0 0 0 '"'" .."' Disclosure of Your Information: Information about you in the Detainee Locator will be shared with any person who conducts a search using your A-Number and/or exact fustllast name and your country of birth. Your infonnation will remain in the Detainee Locator while you � in ICE custody and for 60 days after you are released from ICE custody (for any reason) or removed from the United States. Note: Under Federal law (8 U.S.C. § I367(a)( 2) and (b)(4)), ICE may not disclose infor:mation relating to any individual who has a pending or approved petition for benefits under the Violence Agai.llst Women Act (YA WA), or a pending or approved request for a T Visa (trafficking victim) or a U Visa (victim ofcertain crimes) without fust obtaining that individual's consent to the disclosure. Accordingly, ICE will not place any information about you into the Detainee Locator if you have a.pending or approved VA WA petition or request forT or U Visa, unless you consent. Please notify the ICE officer ifyou have apendjng or approyed VAWApetition or request for T or U Visa. You -will be asked to sign a separate form indicating whether you consent to disclosing your infonnation to third parties through the Detai_ nee Locator. Autho�ity; Collection and use of your information in this manner is authorized by the Immigration and Nationality Act and the Illegal Immigrat:ionRefon:o. and Immigrant Responsibility Act (Title 8, United States Code), and the Homeland Security Act (P.L. l 07-296). , --o/ �-5,, 'rcr �.,,._-_- (' ,-:-.: , No candidate found for the below searched subject. �1 T�e· IDF�1;, ID: Start: 10:05:55 AM 11/17/2017 End: 10:06:31 AM 11/17/2017 Duration: 00:00:36 N 0 N 0 I 0 !:: I 0 0 0 0 en CJ1 CJ1 0 Last 1"ame: SAMIMI First Name: KAMYAR Middle Name: N/A Gender: M Date of Birth: 1953-01-03 (b)(?)(E) State 10 Number: CO2B9976 TIO: l(b)(7)(E) Last Name: SAMIMI First Name: I I KAMYAR Middle Name: Controlling Agency: Search Findings: VA:J0J017Y I 0ccu ation: Treat As Adult: Address: Em lo er Address: Response: FEDERAL BUREAU OF INVESTIGATION CRIMINAL JUST:CE INFORMATION SERVICES D:VISION CLARKSBURG, WV 26306 f b)(?)(E) TC:'-l 0058760964 THE ENCLOSED RECORD, DATED 2017/11/17, WITH THE (b)(7)(E) ND NGI CONTROL NUMBER (NC (b)(?)(E) BEING PROVl:JED AS THE RESULT OF CRIMINAL RETURN iDENT TEN-PR!'-JT SUBMISSION. THE TENPRl:'-JT BIOGRAPHICS AS SUBM'ITTED IN THE ORIGINAL TRANSACTION ARE: NAME: SAMIV.:,KAMYAR DOB 1953101103 A CR:\-iiNAL HISTORY REQUEST NOT:FICATIO'-J(S) WAS SENT BY THE FBI TO THE FOLLOWING ORGANIZATIONS, EXCEPT FOR THOSE INDICATING THAT THE REFERENCED SUBJECT IS DECEASED. COLORADO f b)(?)(E) - STATE ID/CO289976 SINCE THIS RESPONSE CONTA:'lS NAT,ONAL FINGERPR::--JT F:LE (NFF) AND/OR :11 PARTICIPANT STATE(S) REGULATED DATA, THE RESPONSE MAY NOT BE COMPLETE. HOWEVER THE FBI MAINTA:NEJ DATA FROM THE NON"RESPONDING 111 PART:CIPANT STATE(S) :s INCLUDED IN THE RESPONSE. US IMMIG CUSTO�S ENFORCE 2020-ICLl-00006 551 ,,-...._ ICE/ERO DENVER FLO 0 12445 E CALEY AVE CENTENNIAL.CO 8D111 UNITED STATES DEPARTMENT OF JUSTICE FEJERAL BUREAU OF INVESTIGATION CRIMINAL JUSTICE INFORMATION SERVICES DIVISIO>.J CLARKSBURG. WV 263D6 f b)(7)(E) TCN 0058768964 AGENCY CASE 177226850 THE FBI IDENT:FIED YOUR TEN-PRINT SUBMISSION WHICH CONTAINED THE FOLLOWING DESCRIPTORS: NAME SAMIMl,KAY:YAR DATE ARRESTED/FINGERPRINTEJ 2�17/11/17 SEX M RACE w STATE ID NULL BIRTH JATE HEIGHT WEIGHT EYES BROW'l BLACK 15□ 1953/01/03 508 HA;R BIRTH PLACE IRAN CITIZE"JSHI? SOCIAL OTHER BIRTH SCARS-Y.ARKS-TA TTOOS DATES NONE "JONE .\IONE SECUR:TY MISC NUMBERS NONE ALIAS NAME(S) NO'.\lE 2020-ICLl-00006 552 END OF COVER SHEET UNITED STATES :::l!::"ARTMENT OF JUSTICE FEDERAL BUREAU OF INVESTIGAT:ON CRIMINAL JUSTICE INFORMATION SERVICES DIVISION CLARKSBURG. WV 26306 l (b)(7)(E) BECAUSE ADDIT:ONS OR DELETIO�S MAY BE �ADE AT ANY TIME, A NEW COPY SHOULD BE REQUESTED WHEN NEEDED FOR SUBSEQUENT USE. - FBI :JENTIFICATION RECORD WHEN EX?LANAT:O\J OF A CHARGE OR D:SPOSIT:ON IS NEEDED, COVMUNICATE '.JIRECTL Y WITH THE AGENCY THAT FURNISHED THE DATA TO THE FBI. NAME SA'.1,Cvll,KAYYAR l(b)(7)(E) I DATE REQUESTED ,.,... 2017/11/17 (E ) ) ) �----.,,fb (7 ""' --,I =,;;, SEX RACE BIRTH DATE HE!GHT WEIGHT EYES HAR M W 1953101/83 508 145 BRO BLK BIRTH PLACE :RAN PATTERN CLASS l (b)(7)(E) 1(6)(1)(E) C'TIZE:--lSHIP IINIIEJ JAIE : f IRAN ; . RECORD UPDATED 2017/11117 All ARREST ENTR:ES CONTAINED IN TH'S FB' RECOR.::l ARE BASE::> O:--l FINGER?RINT COM?ARISONS AND PERTAIN TO THE SAME INDIVIDUAL. THE USE OF THIS RECORD IS REGULATED BY LAW. IT :s PROVIDED FOR OFFIC'AL USE ONLY AND MAY BE USED ONLY FOR THE PURPOSE REQUESTEJ. U.\JITED STATES JE?ARTMENT OF JUSTICE 2020-ICLl-00006 553 FE:JERAL BUREAU OF INVEST10ATION CRIMINAL JUSTICE INFORMATION SERVICES DIVISION CLARKSBURG, WV 26306 l(b)(7)(E) l(b)(7)(E) ...SPECIAL INFORMATIO'J 0 •• COPIES FOR 'SEND COPY TO' NOT SENT. IF COPIES REQUESTED; YOUR AGENCY SHOULD D:SSEMII\JATE. ................ ...... CRIMINAL HISTORY RECORD ...................... . This rap shee'. was p,od:.iced in response '.o the foi:owing request Subject Narne(s) Stale Id N:.imber C0289976 (CO) C Pu1)ose Code E20173210�0000109962:T A�en:'on The information in :his rap sheet :s subject to the followiig cavea'.s: COLORADO BUREAU OF NVEST:GATION - IDENTIF:CATION UNIT 690 K1PLING STREET, j(b)(6);(b)(7)(C�ENVER, COLORADO so214 (b)(6);(b)(7)(C) �HIS IDENTIF:CATION RECORD IS FOR LAWFUL USE ONLY AND SUMMARIZES l'JFORMATION SE�T TO THE COLORADO BUREAU OF INVESTIGATION FROM F::-.JGER?RINT CONTRIBUTORS IN THE STATE OF COLORADO. U'JLESS FINGERPRINTS ACCOY.PANIED YOUR :N □ UIRY, THE COLORADO BUREAU OF :.WESTIGATION CAN NOT GUARANTEE TH:S RECORJ RELATES TO THE PERSON 'N WHOM YOU HAVE A'J INTEREST. IF THE DISPOS,TION IS NOT SHOWN OR FURTHER EXPLANAT'ON OF AN ARREST CHARGE OR DISPOS:TION IS DESIRED. THAT INFORMATION MAY BE OBTAINED FROM THE AGENCY WHO FURNISHED THE ARREST INFORMATION. ONLY THE COURT OF JUR:S □ICTION OR THE RESPECT:VE DISTRICT ATTORNEY'S OFFICE WHEREIN THE FINAL DISPOSITIO'J OCCURRD CAN PROVIDE A CERT:FIED COPY TO ANY SPECIFIC DISPOSITION. STATE LAW GOVERNS ACCESS TO SEALED RECORDS. BECAUSE ADDITIONS A�D :::lELETIONS TO A cR·:,c�AL H:STORY RECORD MAY BE MADE AT ANY GVEN TIME, A NEW INQU'.RY SHOULD BE REQUESTE::J WHEN NEEDED FOR SUBSEQUENT USE. Subject Narne (s) SAMIM', KAMYAR SAMIMI, KAMI (AKA) SAM!'JI, KAMYAR (AKA) Subjec'. Description Sta'.e '.d Number 289976 (CO Soc'al Security Nurnbe' b)(6);(b)(7)(C) Sex Race 2020-ICLl-00006 554. Male White Height 5'08" ,oa ( Weight Date ofB:rth 1953-01-03 1953-01-30 Hair Color Eye Color Brown Black Scars, Marks, and Tattoos Code Description, Comments, a"Jd lr:1ages v:;ss R FGR Place of Birth FN xx IR Emp:oymen� Occupat:o.:1 SALES Employer UNKNOWN Ocrupa'.1on MANAGER UNK.'JOW\J MECHAN'C Employer Occ:ipabon Emp'oye: yy UNKNOWN Occupafon CAR SALES:,fAN Employer Occupation Employer UNKNOWN AUTO TECH U\JKNOWN Occupa'.,on A UTO DEALER UNK\JOW:-.J Employer Occupation Employer OWNER UNKNOWN UNEVPLOYED UNKNOWN OcC'Jpabon Er:iployer Reside:lce Reside:1ce as of 2016-09-21 6190 FEDERAL BLVD, DENVER CO 80222 Residence as of 2015-12-30 3640 E :v'.ALLAR::l DR, HIGHLAN:JS RANCH CO 80126 Residence as of 2010-12-15 4470 E JEWELL AV, JE\JVER CO 80222 Residence as of 3640 E MALLARD DR, HIGHLANDS RANCH, Residence as of 2009-08-21 3640 E MALLARJ DR, DENVER CO Residence as of 2009-04-27 7123 S QUEBEC ST, CENTENNIAL CO Residence as of 2008-12-03 7123 S QUEBEC, DENVER CO Res:dence as of 2008-06-18 7321 S QUEBEC CT, CENTENN'AL CO Residence as of 2007-09-11 3640 E :V:ALLARD, HIGHLANDS RANCH CO Residence as of 2005-0J-.19 3640 MALLARD DR, LITTLETON CO Res:dence as of 2004-07-20 2020-ICLl-00006 555 3640 E MALLARD DR, H"GHl..ANDS RANCH CO 2004-02-08 3640 E V:ALLARJ DR, LITTLETON CO Reside�ce as of Residence as of 2001-12-01 5630 E WARREN CIRCLE 7108, DENVER CO 1999-10-17 7630 E WARREN CR 7-108, DENVER CO Residence as of 1996-11-07 Residence as of 172KE'JTONST#112,DENVER CO Residence as of 1987-07-01 290 W GRAND AVE #202A, .. •••••••••··••••• .. •-•·• CRIMINAL HISTORY ••••••···•••••··•···•••••• ""'======- ===ec========="'==a===cc== CycJe 001 ===='='===a======'===ccc=cc=-----='=a== Tracking :-lumber 12678122 Ear:,est Eve.it Dale 1987-07-01 Ar,-est Date Arresting Agency S:.ibject's Nar:ie Charge 1987-07-01 CODPD0000 ::JE'JVER PD - IDENT:FICAT'ON BUREAU SAV:".\i'.1, KAMYAR C.1a:ge L1tera: ASSAULT Statute ASSAULT (1399) Co ·Jnts 1 2 Charge Charge Literal ASSAULT Statute ASSAULT (1399) Cmm!s 1 == ====--------"=-"=======-------- Cycle 002 =------ ---== ===== -----------== Tracking Number Earl:est Event Dale 12676123 1996-11-07 1996-11-07 k:est Da'.e CODPD0000 DENVER PD - IDENTIFICATION BUREAU Arres!'ng Agency SAMIMI, KAMYAR SubJect's Na'Tle Charge Charge Literal DR:VING U:-JJER THE INFLUE:sJCE Slatu:e DRIVING UNDER THE INFLUENCE (5404) Counts 1 Severi'.)' MISDEMEANOR 2 Charge Charge Literal FAIL TO AP?EAR S�atute FA"L TO APPEAR (5015 ) Counts 1 =============================== Cycie 003 ===================="'========= 12678124 Tracking Number Ear:1est Eve!ll Date 1999-10-17 Arrest Date Arr,,st1ng Agency S:ibject's Name 1999-10-17 CO0030000 ARAPAHOE COUNTY SHERIFF"SOFFICE SA\f:�I. KAMYAR Charge Charge Literal ARRESTED FOR OTHER JURISDICTiON StatLJ'.e ARRESTED FOR OTHER JURISDICT:ON (4902) 2020-ICLl-00006 556 Counts 1 Charge 2 Charge Literal FAIL TO APPEAR Statu�e FAIL TO APPEAR (5015 ) Coun:s 1 - ===='=============='===c========= C yc:e 004 =======o=============o====-----12678125 Tracking Number 2001-12-01 Earliest Event Date Arrest Date 2001-12-01 Arresting Agency CODPDOOOO DENVER ?D- ::JE:',JTIF:CATION BUREAU SubJect's Name SAMIMI, KA\i'.YAR Charge Charge Literal FRAUD-'V:PERSONATION Statute FRAU:J-IMPERSONATION (26(}4) Counts 1 (Cycle 004) Co-.1rt D1spos'tion Court C ase Numbe, :JOCKET# D0162002CR00046 Final Dispos1t1on :Jate 2002-06-26 1 Charge Charge Lile'.al FRAUD-IMPERSONATION CRIMINAL IMPERSONATION-CAUSE LIAS Seventy FELONY D:spositian (D:SM!SSED BY DA) ----"'-""==========----========= C ycle 0 ::J5 ===c==--===========o=====------= Tcack1ng Number 12678126 2004-02-08 Earliest Event Da'.e Arres'. Dale 2004·02-08 Arresting Agency C00010100 AURORA POLICE ;JE?ARTMENT Subject's :-la'11e SAMIMI, KAMYAR Charge Charge L1'.eral DRUG PARAPHERNAL!A-?OSSESS Statute DRUG PARAPHERNALIA-POSSESS (3550) Co ·Jnts 1 Severity MISDEMEANOR 2 Charge Charge Literal COCAINE - POSSESS Statu'.e COCA:.',.JE - POSSESS (3532 ) Counts 1 Severi:y FELO:-JY Cha:ge 3 Charge Literal ARRESTE:l FOR OTHER JURISDICTION Sta'.·Jte ARRESTED FOR OTHER JURISDICTION (4902) Counts 1 Seventy v.:s::iEMEANOR =============------============ Cycle 0 06 ===== -----==-=====,,=========== T•acking Nurl'ber 12678128 2004-07-20 Earliest Event Da�e Arrest Date Arresting Agency 2004-07-20 C00030000 ARAPAHOE COUNTY SHER:FF'S OFFICE Subject's Name SAMIMI, KA.VYAR Charge Charge Lite�al DANGEROUS DRUGS Statute DANGEROUS DRUGS (3599 ) COU"l!S 1 Seventy FELONY Gour: Dispos,:'on Court Case Number (Cycle 006) DOCKET# D0032004CR001437 2020-ICLl-00006 557 Fina; Disposition Date 2009-03-09 Charge t 1 Seventy FELO:>N D1sposrt;on (GUil TY) Sen'.encing (Cycle 006) Charge 1 Cha:ge U�era: CONTROLLED SUBST-POSSESS SCH 2-1G D1spos:�on (2009-03-09; 6':00 H COrv'.MUNITY SERVICE MU:-JITY SERVICE) ========-=ca===="="'==cc===="='==== Cyc· e 007 "==========ce====a======='=--=a=== Tracking Number 12678130 Earliest Event Date 2005-03-19 Arrest Date 2005-03-19 Arresting Agency CO0030200 LITTLETON POLICE DEPARTMENT Sub'.ect's Narr.e SAMIM', KAMYAR Charge Charge Litera! ARRESTED FOR OTHER JURISDICTIO:-J S:atute ARRESTE) FOR OTHER JURISD:CTION (4902) Co: mts 1 . Severity FELONY Charge 2 Charge Ueral ARRESTED FOR OTHER JURISDICTION Statu'.e ARRESTED FOR OTHER JUR:SDICT"ON (4902) Counts 1 Seventy MISDEMEANOR Cha'>)e 3 Charge L,te�I ARRESTED FOR OTHER JURISDICTION Sta�ute ARRESTED FOR OTHER JURISDICTION (4902) Cou:its 1 Seven� MISDEMEANOR Charge 4 Charge L1le�al ARRESTE:J FOR OTHER JURISD:CTION Sta'.·Jle ARRESTED FOR OTHER JURISDICTION (4902) COU'llS 1 Severi'.y MISDEMEANOR Court D'spos1tion (Cyc:e 007) DOCKET# D00320D4CR001437 Gour: Case Number F:nal Dispos'tion Date 2005-06-09 Charge 1 Charge L1lera· :JRUG PARAPHERNALIA-POSSESS DRUG PARAPHER"JAL,'A-?OSSESS Severity MISDEMEANOR D1spos1t1on (GUILTY) ---- ---==============------==="' Cycle 008 =======---======='='======== ---12678131 Tracking Number Earl:est Event ::late Arrest Date 2005-,05-21 2085-,05-21 A�est1ng Agency C00010108 AURORA POLiCE DEPARTMENT S:ibject's Name SA�;MI. KAMYAR Charge Charge L1'.era; MOVING TRAFFIC VIOLATION Statute MOV::-JG TRAFFIC VIOLATION (5405) Counts 1 Severity MISDEMEANOR Charge 2 Charge Literal FAIL TO APPEAR Sta!ute FAIL TO APPEAR (5015) Counts 1 2020-ICLl-00006 558 Charge Seventy M!SJEMEANOR 3 Charge Literal NON:V:OV:NG TRAFF!C VIOLATION Statute NONMOVING TRAFFIC VIOLATION (5406) Counts 1 Severity MISDEVEA.\JOR = ------ - ======= ===-----= == ===== Cycle 009 ==== --- ============-------=== = Traciiarge 2 Charge Literal ARRESTED FOR OTHER JURISD:CTION Statute ARRESTED FOR OTHER JURISJICTION (4902) Counts 1 Severity .v:s::iEMEANOR =======---======'"'===== == =- =---- Cy cle 018 ====== =-----=-==='======== =---Tracking N;,,rr�bec 12678141 Earliest Event Date 2009-12-29 A:---est Da'.e A:-Testing Agency 2009-12-29 CO0010400 THORNTON POL"CE DEPARTMENT SAY::V.I, KAMYAR S;;bject's Nar:ie Charge Charge Literal THEFT Statute THEFT (2399) Counts 1 Seventy Y.:SDEMEA:-JOR ----==--======== =-=== ====== ===== Cycle 019 c==, =====---===-==co======== = --=1267 8142 Track1ng Nu�ber Earliest Event Da'.e 2010-04-10 Arrest Date 2010-04- 10 Arresting Agency CODPD0000 DENVER PD- "JE\JTIF:CATION BUREAU SAMIMI, KAY:YAR SubJec:'s Name Charge 1 Charge l'teral SHOPLIFT::-JG Statute SHOPLIFTING (2303) Counts 1 Cha•ge 2 Charge Lite,al TRESPASSING Sta:.ite TRES?Ass:NG (5707) Counts 1 3 Charge Charge Literal TRAFFIC OFFE:-JSE Statute TRAFFIC OFFENSE (5499) Counts 1 ---======= ==============='====== Cyc le 020 ========================== ---TraciDLE NAIJIE. SL."FFIX SAM:MI, KAMYAR SOCIAL SECUlilTY NO. LEAVE BLA!'.K LAST NA.ME. FIRST NAME, MID:::LE NAME. SUFRX STATE IDENTIFICA710N .�O. b)(7)(E) DATE CF 81RTH MM DD VY 2. R. l!l.:□ EX ;;__?� LEFT FOUR FINGERS T>l,KEN Sl:vliJLIANEOUSLY RIGH'T'FouR FINGERS'7AJCEN SIMULTANEOUSLY 2020-ICLl-00006 565 FEDERAL BUREAU OF INVESTIGATION, UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES OIVISION,CLARKSBURG, WV 26306 !he FBl's _acquis:�on, P"!servaUon, and oxchar.go of idenli_fication infarmw"'" •. · geeerally aulhorized under 28 USC 534. This FD-249 is to be used r-·•. ,-,,ina: justa purpose �. su::11 as incident to arrests and 1ncarcerat1ons. Toe Applicant form (F0-258) contams appl1eallle Paperwd, ;e purposes. "A Soc,al Secun!y Acco·�r.t Ncmber (S.SAN JliCIJOn Acl and Pm,acy Act noti� and should ba used foe noncrim,r, is he'ptul lo ke,>p =rds accurate becaL;Se other people may �ave the sa,,._ .. ame and birth date. Pursuant to the Fod-MO) JUVENILE FINGEq?R:n DATE Of ARRE51 ORI )(7)(E) t SU6M'SSIO� MV. Y£S 0:J yy CO�T�IBU�O TREAT AS ADULT YES SEND COPY 10, (ENTER ORI) □ □ I :.1/17/2017 DATE OF OFFENSE MM ADDRESS YES REP�Y OESIRE�' DO Ill--•,� "11 Thorr.to�1,;Y;-_ CO □ PLACE OF 81RTH (STA�E OR cou,.,-rRYJ COUN':"AY OF CITIZENSWP IRAN VY IRAN SC AAS, .'-4AAKS, TA, roos, ANO AMPU'tAT'ONS �ISCElLANEOL.'S NUMBERS CR:P R E'GR-Ir.dex finger ALIEN-022732918 RESIOENCE/COMPLflE ADDRESS CITY LOCAL JOENTIF1CA1 IONIREF'E.RENCE PrlOlO AVAl:.A8LE1 Thorr:.:.0:1 900:. Poze B'...vd. OFFICIAL "':"AKING �INGEAPRINTS (NAME 0� NUMBER) (b) {6);(b)(7)(C) ii :cr.p� Auto ,490 F�de:al S:.vd [ b)(7)(E) SPECIFIC AGENCY. ERVICE AND SERIAC NO. I Ocv�, CO 8:121 :JS 0CCL,'PA7'0N Auto ':eel- CHAAGe1c,rATION '8 t'SC :.217 - DE?CRTAllLE AC,:ZN. 01$POSITION \. 2. 2. J. ). ADOIT10NAL AODl110NAC ADDITIONAL INFORMATION/BASIS FDA CAUTION STATE BUREAU S"':"AMP - U .S. GOVERNMEN T PUB�ISHING OFFICE. 05/2.512017 13. 1 7.15 _ 2020-ICLl-00006 566 PA�M PR:N rs TAl(fN? S":ATE co ns YES C C: R-� (Rev. 04-10-2014) OMB-1110--0051 ( FINALDISPOsmo.� FINS f:1238805650 -:::;: No., o,,u:11000321 I LcaveBlmk Toe FBfs acquisition, prlelicrvalioa, and exchange of identification info=ation is generally authori2cd under 28 USC 534. This R-&4 '------------­ is to be used for crii:ninaljustice purposes, such as incident to arrests and incarcerations. The needs and uses for this information is covered in the Fingerprint Identification Records System (FIRS) System of Records Notice (SORN), published in the Federal Register on September 28, I 999. "A Socfal Security Accouot Number (SSAN) is helpful to keep records accurate because other people may have the same=• and binh date. Pumia,nt to the Federal Privacy Act of 1974 (5 L"SC 554), any Federal, State, or local govcmmenc agency which requests an individual to disclose his/her SSAN is l"CSIJonsiblc for informing the person whether disc105U?e is mandatory or voluntary, by what statutory or other authority the SSAN is solicited, and what uses will be made ofiL • Note: This vital report must be prepan:d on each subject who5C arrest fingerprints have beai f01Wardcd to the FBI Criminal Justice Information Services Division without final di.�position noted. If no final disposition is available from artesting agcncy, complete left &ide and forward the form wheo case is n:fem:d to prosecutor and/or courts. Agency on notice as to final disposition should complete this form and submit to: FBI, CJIS Division, Clarksburg, WV .26306. (See instmctiollS on reverse side) b)(7)(E) •• final Disposition Due ··Name on nngC1print card submitted to FBI Last First I Middle (The convicting offense STATIJTE, SUBSECTION, LEVEL of conviction, md sentencing informa.ti.oa is to be included as pan of the dispositiOll. If convicted or subject pleaded gwlty to Jessa- charge, inclurle this information also.) SAMilfi, RAMY.AR ._Date of Birth □ 01/03/1953 Disposition Maintenance Indicator (DMI) AppClld 0 Add State Bureau No. (SID) I Sex 0 Replace Mal.e - -- D Dclete Social Security No. (SOC) 0 No Record per: •• Form Submiucd by ORINtunber I CO289976 *•Fingerprint Contnllutor/.Arresting Agency ORJ I (Kame, Title, Ag�cy, City & State) Include complete name and locatioo of agency Denver Field Office 12445 E ca.l.ey Ave Arrest No. (OCA) Signature Title D COURT ORDERED EXPUNGEMfiliT Ce:rti1icd or Authenticated Copy of Court Ordr:r Attached. "'-Date Anwed or Received ll/17/2017 022 732 918 Date □ □ □ Subject's Rclatiooship to Victim: Current or former spouse of victim (can be same sex) Guxrdia.r1 of victim Person is cohabiting or has cob.abitai as spouse of victim (e&n be same sex) D Person is cohabiting or has cohabited as parent of victim O Pcn,on similiirly situated to spouse (can be same sc:x) □ Pcrsllll similarly sitnated to p=t ofvictim Ot her______________ ...Offenses Charged at Anesi rem prcc; □ □ □ Parcnt/Stcppare.ct of victim Child in common (c.bild lllllSI be born) Person is cohabiting or has cohabited as guardiaD of victim Pason sunila:rly situated to giwdian ofvictim • . f.>'·,·= . ' . !.EfT FOUR ffilGa\S TAKEN SlldL"l.TA.'1.llOUSLY □ □ LTHUMB Jl n-n.-wi 2020-ICLl-00006 567 lUGHT FOUR FINGERS TAK°El'I SIMUl.TAh'EO\;SLY INSTRUCTIONS 1. The purpose of this report is to record the initial data of a subject's arrest and secure the final disposition of the arrest at the earliest pcissible time. The SUBJECT'S NM1E, CONTRIBUTOR AND ARREST NUMBER sh ould be exactly the same as submitted at the time of arrest. The FBI number should be indicated, ifknO\vn. The agency ultimately making final disposition must complete and submit form to their designated state or federal agency. 2. The arresting agency should fill in all arrest data on left side of form as the contributor of the fingerprints. The arresting agency ORI should be placed in the appropriate block. If the arrest is disposed ofby the arresting agency, as where the arrestee is released without charge, the arresting agency must fill in this final disposition and mail form to their designated agency. Of course, if the final disposition is known when the arrest fingerprint card is submitted, it should be noted on the fingerprint card and this form is then unnecessary. In the event the case goes to the prosecutor, this form should be forwarded to the prosecutor with arrestee's case file. 3. The prosecutor should complete the form to show final disposition at the prosecution level if the matter is not being referred for court action and submit form directly to their designated agency. If court action is required, the prosecutor must forward form with case file to court having jurisdiction. 4. The court should complete this form as to final comt disposition such as when arrested person is acquitted, case is dismissed, conviction/sentence imposed or suspended, or person placed on probation. 5. When arrested person is convicted or pleads guilty to a lesser or different offense than when originally arrested, this information should be clearly indicated. 6. If court disposition is associated with a misdemeanor crime of domestic violence, select the appropriate box demonstrating the relationship of the subject to the victim, and attach the police/incident report/court record to this form. If other is selected, please provide the description of the relationship to the victim in the space provided. 7. If subsequent action is taken to seal or expunge record, attach certified or authenticated copy of court order to this form. 8. If the disposition was destroyed, purged, or is no longer available, please check the "No Record" box and indicate agency. 9. It is vitally important for completion of subject's record in the FBI Criminal Justice Information Services Division files that Final Disposition Reports be submitted in every instance where fingerprints were previously forwarded without final disposition noted. IO. Submission of.flat capture fingerprint impressions is optional. 11. Asterisks indicate mandatory fields, but all known data should be provided. 0 0 -'0 r 0 0 0 0 _l ,- . To: From: 7 i · (Jb (6J;:1:w __ _o��, _ _ _ij_:{_ r_,.__. � �V--1 - �--' � ��\vi_ _ °\ . Q._J½ _ �lo tid . 11\) u _ ' \ '-{_-(_ CU\ ) ���LlJ_,��---- E\�J\A.<--. l . � __ _ 4-l., . d..o0..t. � �:. ,._,.__ J c:. ,._,,_ �:.Q, f'�---. a I.Ut_;.0._____ e:si. --·- . u.>� i � \ u..d...?. ,t,.. l.r- l::,o ""' ��½ �- �fr lv -:>cud �La...v� _ 1 oU 1 ,'~_ � S-:- --\-lQ. (.._ l,� -.}.J.:;:-- __ L, Q,,,:l� �-DJ- L-(__ ____� .. 00.d . \,v;, v-..._� -�>J_ _ \_ =r-�. �- 6 __ b: '"''(----� l.LJ O .:,. . \..u,u ..UA_ -d...,.,j_ --- --�-�--�- ;s _ 2.1 ��k___ � � \ �'e��M �:� h'_':?_',__ - Lv_��_:AA \ 1'., ' -l)..)_0.0 . ___ lot«v, kJlQ�_ -vJ,...�-�-- --=----t.::J-r-_0__ �------ - -. __B.'.<_ - --- - --- -.!-:L .- s .. _ � d...o _ ---%dr�-•(.__QJ,- .. �(ti Leu�-- � V,£.,1, to_d - -- -- (b)(6);(b)(7)(C) _ _ u �- --)I.} �---+---· - ---- . '<:- 1 \_i_ �-t ⇒-�-g L 2020-1cu�oooos 571 1v« � t-J07 � o0_{> t IY'- D a. Lh..__ � y::,d,._. u._..,j _ UNITED STATES DEPARTMENT OF JUSTICE Immigration and N•tur•lizalioa Service ,-II.If NUMIIUI A22 732 918 P4TE • 16 December 1986 FAILURE TO APPEAR FOR THIS INTERVIEW WILL RESULT I� YOUR APPLICATION BEING DENIED FOR LACK OF PROSECUTION. Kamyar Samimi 1591 East Kettle Avenue Littleton, Colorado 80122 FINAL NOTICE -f Please come to the office shown below at the time and place indic.ted in connection with an official mallet. OFFICE LOCATION (-!JATE AND HOUR I ASK FOR I [ HtASON FOR APPOINTMENT BRING WITH YOU trNS Champa St. Entrance federal Bldg.l Denver,. Colorado 23 December 1986 - 1?-!XlGMTlON OFP�CER Room Nu. 11:15 am ni _ (b)(6);(b)(7)(C) J l Floor No. .. .. � I APP1.N�ATI0N FOR A NATURALIZATION CONTI�QED FOR QOCUMENTATION SEE BELOW IT IS IMPORTANT THAT YOU KEEP THIS APPOINTMENT AND BRING THIS LETTER WITH YOU. If you arc unable to do so, !IJ!c your reason, sign below and return thi<' letter to this officr. al once. \ \ l. \ 1 b)(6);(b)(7)(C) I am unaL!e lo keep the appointment because: ., I --r_DA_T_E__---1 _______________ T _R_l! I _N_A_U \.jr---5-G '·,---------------------'-------' \rm C-56 \. �-I-HJ N I 2020-ICLl-00006 572. ··1· - UNITED STATES DEPARTMENT OF JUSTICE !MMIGRATJON & NATURALIZATION SERVICE PLEASE ADDRESS REPLY TO 1 787 FEDERAL. OFFICE BUil.DiNG DENVER. CO 80202 ANO REFER TO THIS FrLE NO. A22 732 918 KAMYAitease obbsl your .serologic report. X--d date irldicaled belo\lj: Please� mm,rctiately with 1he below- Isled� or M1t1 one of !ti,, ptrysici,,ns on t1,e attach8d fist, ii a ht is altadled. (11 to ascer· 1am wtllll � you should make to obtain a serologic report, X-ray fin, al'ld reBding prior to your medical e>II examinalmn by tlim. which must be �eted belore . yoar int:erlll"iev.. . . . ,.,. � ,., con,,ectir,,1 with lhs ....amirtation must be paid by you. I PI-IYSIClMi'S N'-ME. ADORESS, ANO 1ELEPHONE NUMBER attvbed tat .. See Plislllse show Jn,s_ letter lo .-.y lmor.dory pe,forming tests Also � the COl"eS of this letter lo the physicoan perlorming !"8 medical e�. and furT,i;, him witll YOU'" sigrl.llure wnnen In� prese,,c,i tor fndusmn with his rep()rt __J INSTRUCTIONS FOR IMMIGRATION INTERVIEW AN APPOl'flMENT HAS ALSO BEEN MADE� AN INTERVlfW BEFORE .\N !MM�.\TION OITICFR AT o,nc TIME I 111t.7 9, 1979 1:00 p.a. BRING WlTl,I YOU AT THE TIME OF INTERVIEW THE, FOLLOWING· 1 2. 3_ The sealed envelope turmshed fo you by the physician who performed t!le med;caI eyminalion. Your passport and Form 1 9 - 4.. (Arnval and � Record) Support. Affidavit and briog -=•-=tt:ead ==--;•=hi=•=-===•=lriyou=· =th================= o"'"'c.,,aplete OTE: aloag tl>e encloaed of line your wi- IF YOU DO NOT $PEAK ENGUSH . . A PERSON OF YOU!'f OWN SEX WHO CAN ACT AS INTERPRETER S ACCOMPANY YOU TO THE MEillCAL EXAMINATION ANO IMMIGRATION MEl'IVIEW .- ' � tAILURE TO KEEP THESE APPOINTMENTS AND TO BRING THE REQUIRED O(X;I.JMENTS WILL DELAY YOUR CASE BRING' l"ASSPOAT. ANp l-!!-4 ',----w; \1-10-76) Y District OlreclOt'" \ File Copy 2020-ICLl-00006 575 OULD � � _,_., fe_J - ··1·. FOJIM G-32SA (REV. 10-1-74) Y For Sale by . BIOGRAPHIC INFORMATION ,, [family oome) . . �::;:__.. ) IQ! .�IlfTMT (First name) - - ··-- I Am.MI lrrimisi'ration and Naturalization Service tr;.. ·;;uperintendent of Documents, {Middle norr.e) K.AMYAR FATHER MOTHER(Mciden noll).e) FIRST NAME FAMllY NAMt l!J•ALE �--- □ FEMAtE ! BIRTHDATE(Mo.-Dcy-Yr.) J an/1/ 5] OT'f ANO COUNTRY OF BIRTH IR.AJ.1 .HiJ✓..ADA.'i F.ORMER HUSBANOS OR WTVES(if nont, so ,iore) FAMILY NAME (For wile, giv• maiden nam•) I BIRTHDATE ] DI.a.NE FIRST NAME !I 68�8 .l!JVJli\i� Api,ff SCP.ROJ:W� Ib.:'.9 .l!i j).1. l:i"C V! WU\J.I) JlVe l)JU V�� Ave ::::'., ff �j ff ff l. � CITY ug!'lk.osn. PROVINCE OR STATE Maal!!Orl t1' .. _ ft. Denv�r vUl.iU.tt.i,J)U u. t,· • ... ue!'lkoen j'-j pA-'°1..K W£1. .ilpt ff ::; ClTT .l..'tl.K.Al'J FR0"'4 .LJeaJ It.pr;, i,ep1, u • l:l• .a.. Wl.l:5livJ.'i �.1.1\1 PROY(NCE OR STATE .a.pr/ JriitONTH APPLICANT'S EMPLOYMENT LAST FIVE YEARS. {IF NONE, SO STATE.) LIST PRESENT EMPLOYMENT FIRST J a.."1/ OCCUPATION 1sPEc1 rY 1 FUll NAME ANO ADDRESS OF EMPLOYER TO MOl' B't U.W Rlll kHOWINGLY MD WIUflJU.T fALSlmNc> OR CONCEAUNG A IIAm!IAL FACT. 2020-ICLl-00006 576 I ,,.,s 5PAC(; EXECUTIVE OFFICE FOR IMMIGRATION REVIEW IMMIGRATION COURT 3130 N. OAKLAND ST. AURORA, CO 80010 In the Matter of: File Number: A# 022-732-918 KAMYAR, Samimi Respondent( s) ORDER OF THE IMMIGRATION JUDGE Upon consideration of ( ) Respondent's/Counsel's (✓)Government's (✓)motion to ( ) request for: ) Continue hearing - Scheduled for____ Hearing for: _____________ ( Advance hearing date - Scheduled for____Hearing for: _____________ Telephonic appearance of: ( C Attorney n Witness ( ✓ ) Reassign Case It is HEREBY ORDERED that �he above motion be �RANTED n DENIED because of the reason(s) set forth below: I· There being no opposition to the motion. �ood cause has been established for the above request. C No statement of opposition to the motion/request has been filed with this Court C Government opposition was filed, but Court found overriding factors in favor of the Respondent. C No good cause has been established for the above request. r On account of the reasons set forth in the opposition which was filed. C-------------------- �' It is HEREBY ORDERED that this matter be rescheduled to a _____________ Date \'2-1 S I L Master C Individual hearing on _ _ at_ _ _ _ _ _ _ _ _ � '1M-- � ¼(1 NINA M. CARBONE IMMIGRATION JUDGE CERTIFICATE OF SERVICE PERSONAL SERVICE ( :,,,),> MAIL ( ) THIS DOCUMENT WAS SERVED BY: 17 J �ATT/ru:� Officer Cu,s.u:>.Qial c/o ALIEN ] [ [ ,+,.ALIEN TO: ntt.Ti:::- \1'.LC:.._IF"l RV- rnT���il,.!,900065 � OFFICE OF THE CORONER Adams & Broomfield Counties Monica Broncucia-Jordan CHIEF CORONER December 11, 2017 To Whom It May Concern, This letter is to certify that Kamyar Sarni mi, date of birth January 3, 1953 was pronounced deceased on December 2, 2017. If you have any further questions please contact our office. Sincerely, (b)(6);(b)(7)(C) Operations Manager Office of the Coroner, Adams & Broomfield Counties .., 330N. 19TIIAVE. BRIGHTON, CO 80601 2020-ICLl-00006 578 �(b)(6);(b)(7)(C) F 303.659.4718