SOP 209.06-att-4: Administrative Segregation Assignment Appeal Form
Summary
Key Topics
- administrative segregation
- segregation appeal
- disciplinary segregation
- offender appeal process
- Classification Committee
- housing assignment
- segregation hearing
- inmate appeal
- disciplinary review
- segregation decision
Full Text
SOP 209.06
Attachment 4
2/19/21
ADMINISTRATIVE SEGREGATION
Assignment Appeal Form
I. Offender: ___________________________ GDC #: __________________ Date: _____________
II. Administrative Segregation:
In accordance with SOP 209.06, Administrative Segregation, an assignment to Administrative Segregation was made
based upon the following:
_______________________________________________________________________________
_______________________________________________________________________________
III. Offender's rebuttal: (within 3 business days after the 96-hour hearing, submit to the Counselor, who will forward to
the Warden/Superintendent).
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
DATE APPEAL RECEIVED: _______________________ BY: __________________________________________
IV. Review of Appeal
I concur / disagree with the Classification Committee’s Action. The following decision(s) has/have been made
in this case.
A. ____ Remain in Administrative Segregation
B. ____ Return to Appropriate Housing Unit
________________________________ _______________________
Warden/Superintendent Signature Date
Copies: Offender Offender file
-------------------------------------------------------------------------------------------------------------------------------------
OFFENDER RECEIPT FOR ADMINISTRATIVE SEGREGATION
OFFENDER’S NAME: ______________________________________ I.D. #: ______________________
I ACKNOWLEDGE RECEIPT OF THIS APPEAL FROM THE ABOVE OFFENDER.
DATE: ___/___/____ COUNSELOR’S SIGNATURE: ____________________________
Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file and maintained according to the
official retention schedule for that file.