Fill and Sign the Nurse Give Form

IN THE ________________ COURT OF __________________ (County), ______________________ (State) __________________________ PLAINTIFF (Name of Plaintiff) V. CAUSE NO. _____________ __________________________ DEFENDANTS __________________________ __________________________ (Name of Defendants) COMPLAINT COMES NOW ______________________ (Name of Plaintiff) , Plaintiff in the above-styled and numbered cause, by and through his attorney, and files this his Complaint against Defendant [State whether Defendant is in United States or a State (name of state) and give name of prison and whether or not it is a state or federal prison) ________________________________________________, hereinafter called Correctional Institute , and Defendant ____________________________ (Name of Defendant Nurse), hereinafter called Nurse, and in support thereof would show unto the Court the following matters and facts: I. Plaintiff is an adult resident citizen of ___________________________________ (city, county, state) , and at all times during the occurrences described below, was an inmate at Correctional Institute . II. Defendant __________________________ (name of nurse), hereinafter called Defendant Nurse , is an adult resident citizen of ________________________________ (city, county, state) . III. At all times mentioned, Defendant, (the United States of America or State of (Name of State) ________________________________________________, operated the Correctional Institute, a _____________________ (state or federal) prison located at ____________________________________________________________________ _______________________________ (street address, city, county, state, zip code) . IV. This action arises under the (either the Federal Tort Claims Act, Sections 2671 through 2680 of Title 28 of the United States Code or the State’s Tort Claims act – cite section of State’s Code) ________________________________________. This Court is vested with jurisdiction pursuant to (Section 1346(b) of Title 28 of the United States Code) _________________________________. V. On ___________________________ (date of admission) , Plaintiff was admitted as a patient to the infirmary of the Correctional Institute due to (describe symptoms or illness) ___________________________________________________ ______________________________________________________________________. VI. At all times mentioned, Nurse was a contract employee working at said infirmary, and was under the direct supervision and control of the Correctional Institute regarding her day to day duties. VII. Plaintiff had been prescribed the medication _____________________________ (name) for ______________________________________________________ (reason) by _______________________________ (name of physician) on or about ___________________________ (date) . Plaintiff was to receive this medication ___________________________ (how often) . It was Nurse’s responsibility and duty to administer this medication; however she negligently failed to do so. VIII. As a direct and proximate result of the negligence of Nurse , Plaintiff suffered (describe) _____________________________________________________________ ______________________________________________________________________. IX. As a direct and proximate result of the negligence of Nurse , Plaintiff also suffered (describe) ______________________________________________________ ______________________________________________________________________. X. As a further direct and proximate result of the said negligence of Nurse , Plaintiff will incur substantial medical and hospital expenses after release from incarceration in a sum exceeding $______________. (If under Federal Tort Claims Act or if State Claims Act so Requires): XI. On ___________________________ (date of claim) , Plaintiff submitted a claim of $______________ (dollar amount) to _____________________________________ (name of federal agency) . XII . By _________________________ (date of pending claim) the _____________ _____________________________ (name of federal agency) had neither accepted nor rejected the claim and, pursuant to 28 U.S.C.A. § 2675(a), Plaintiff elects to consider the failure to act as a final denial of the claim. WHEREFORE, Plaintiff requests judgment against Defendant : 1. In the amount of $____________, as damages; 2. Awarding Plaintiff the costs of this action; and 3. Granting Plaintiff such other and further relief as the Court deems just and proper. Respectfully Submitted, _____________________________ Name of Plaintiff By: __________________________ Name of Attorney Bar No. _____________ Of Counsel: Attorney for Plaintiff Post Office Box ________________ ______________________________________ (City, State, Zip Code) Telephone: ______________________