SOP 209.06-att-3: A, Segregation_Isolation Checklist-12 Hour Shift

Attachment 3A
WARDEN’S/DESIGNEE'S REVIEW SOP 209.06
AFTER DISCHARGE (SIGN.): _______________________________________________________________ 2/19/21
SEGREGATION/ISOLATION CHECKLIST – 12 HOUR SHIFT (Page 2 on Back)

OFFENDER NAME: NUMBER: RACE:
PRIOR LIVING UNIT: COUNSELOR: PRIOR JOB DETAIL:
DATE COMMITTED: EXPECTED DISCHARGE DATE: STATUS:
TIME COMMITTED: ACTUAL DISCHARGE DATE & TIME:
REASON FOR ASSIGNMENT:

PERTINENT INFORMATION:

|Date|Shift|Meals|Col4|Col5|SH|EXER|COMMENTS
(Include note/sig. of staff
visits, such as medical)|ADM
REV:|OFFICER
SIG:|
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EXPLANATORY NOTES: Meals - Yes(Y) or No (N) or Refused(R); Shower (SH) - Same codes as meals; Exercise (Exer) - Enter actual time period (e.g. 9:15AM

- 10:30AM Inside)
PERTINENT INFORMATION: Epileptic, Diabetic, Religious Diet, Suicidal, Assaultive, etc.

COMMENTS: General conduct, attitude, hygiene, sanitation of cell (continue on back if needed).

ADMINISTRATIVE REVIEW: Asst. Warden or Duty Officer, Shift OIC/Captain, as appropriate

Retention Schedule: Upon completion of this form, it will be placed in the offender’s case history file.

Attachment 3A
SOP 209.06
SEGREGATION/ISOLATION CHECKLIST-12 HOUR SHIFT 2/19/21
30-MINUTE OR 15-MINUTE WATCH Page 2 of 2
Segregation/Isolation Observation Record (Back of Page 1)

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Retention Schedule: Upon completion of this form, it will be placed in the offender’s case history file.