SOP 209.07-att-3: Segregation: Tier I Program Assignment Appeal Form

Attachment 3
IIB09-0002 (209.07)
04/30/15
SEGREGATION: TIER I PROGRAM
Assignment Appeal Form

I. Offender: ___________________________ GDC #: __________________ Date:_____________

II. Disciplinary Segregation: Tier I Assignment

In accordance with Tier I SOP, an assignment to the Segregation: Tier I Program was made based upon the following
explanation:
_______________________________________________________________________________

_______________________________________________________________________________

III. Offender's rebuttal: (within 3 business days submit to the assigned counselor who will forward to the Warden)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

DATE APPEAL RECEIVED:_______________________ BY:__________________________________________(COUNSELOR)

IV. Review of Appeal
_____I concur / disagree with the Segregation: Tier I Program Classification Committee’s Action. The
following decision(s) has/have been made in this case.

___________________________________________________________________________________

_________________________________________________________________________________

___________________________ _______________________
Warden’s Signature Date

Copies: Offender Offender file
RETENTION SCHEDULE: Upon completion of this form, it will be placed in the offender case history file.
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OFFENDER RECEIPT FOR SEGREGATION: TIER I ASSIGNMENT

OFFENDER’S NAME: ______________________________________ I.D. #: ______________________

I ACKNOWLEDGE RECEIPT OF THIS APPEAL FROM THE ABOVE OFFENDER.

DATE: ___/___/____ COUNSELOR’S SIGNATURE: ____________________________