SOP_NUMBER: 209.06-att-4
TITLE: Administrative Segregation Assignment Appeal Form
REFERENCE_CODE: IIB09-0001
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2021-02-19
WORD_COUNT: 150
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/292423
URL: https://gps.press/sop-data/209.06-att-4/

SUMMARY:
This form is used by incarcerated individuals to appeal their assignment to Administrative Segregation within the Georgia Department of Corrections. The offender has up to 3 business days after a 96-hour hearing to submit a written rebuttal explaining why they should not remain in segregation. The Warden or Superintendent reviews the appeal and decides whether the offender should remain in Administrative Segregation or be returned to regular housing.

KEY_TOPICS: administrative segregation, segregation appeal, disciplinary segregation, offender appeal process, Classification Committee, housing assignment, segregation hearing, inmate appeal, disciplinary review, segregation decision

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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FULL TEXT:
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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.