SOP 209.06-att-5: 7-Day Segregation Status Review Form

SOP 209.06

Attachment 5

2/19/21
# 7-Day Status Review Form

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Type of Segregation: Administrative Disciplinary Medical Protective Custody

On _______________________, at ___________ hours, I, ______________________________________ conducted a

7-Day Status Review on Offender ________________________________ ID #______________.

Original Reason for Placement: ______________________________________________________________

Date Segregation began: ____________________________________________________________________

During this review, the following factors were considered with the results as indicated:
YES NO
1. Were there any negative comments documented on Attachment 3/3A?
2. Does the offender pose a threat to security/themselves/others/property?
3. Did any Unit staff member(s) report any negative behavior or acts since last review?
4. Is the offender unwilling or unable to live in general population? (PC Only, explain below)
5. Was the offender’s behavior defiant or insubordinate, during the review?
6. Has the offender received any disciplinary reports since the last review?
7. During your review did the offender make any statements that concerned you? If so, document below.

If any of the above factors are marked “YES”, the offender must continue their existing status, unless the
Warden/Superintendent determines otherwise. If all factors are marked “NO”, the offender may be released. Comments
regarding your review will be made below. The Authorized Staff Member conducting the Review shall be responsible for
entering the review results into the Offender’s Case Note in SCRIBE. If number 2, is “YES” the Authorized Staff Member
will notify the Segregation Unit Manager and the Mental Health Director/Counselor (complete a Mental Health Referral at
Non-Mental Health Facilities).

COMMENTS:
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For the reasons documented above, I recommend:

 Remain in Administrative Segregation
 Return to appropriate housing unit

Authorized Staff Member: __________________________________ Date: _________________________

Warden’s Recommendation:

 Investigate and provide additional information on the following: ______________________________________
 Return to General Population (appropriate housing unit)
 Continue Current Segregation Status

Warden/Superintendent: ___________________________________ Date: _________________________

Retention Schedule: Upon completion, this attachment shall be maintained for one (1) year and then destroyed.