SOP_NUMBER: 209.06-att-3
TITLE: A, Segregation_Isolation Checklist-12 Hour Shift
REFERENCE_CODE: IIB09-0001
WORD_COUNT: 277
URL: https://gps.press/sop-data/209.06-att-3/

ATTACHMENTS:
  1. Offender Assignment to Segregation - Administrative Segregation Assignment Memo
     URL: https://gps.press/sop-data/209.06-att-1/
  2. 96-Hour Segregation Hearing Report
     URL: https://gps.press/sop-data/209.06-att-2/
  3. A, Segregation_Isolation Checklist-12 Hour Shift
     URL: https://gps.press/sop-data/209.06-att-3/
  4. Administrative Segregation Assignment Appeal Form
     URL: https://gps.press/sop-data/209.06-att-4/
  5. 7-Day Segregation Status Review Form
     URL: https://gps.press/sop-data/209.06-att-5/
  6. Administrative Segregation Orientation Handout
     URL: https://gps.press/sop-data/209.06-att-6/

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**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<br>(Include note/sig. of staff<br>visits, such as medical)|ADM<br>REV:|OFFICER<br>SIG:|
|---|---|---|---|---|---|---|---|---|---|
|<br> <br>**Date**<br>|<br> <br>**Shift**<br>|**B **|**L **|**S **|**S **|**S **|**S **|**S **|**S **|
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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.