SOP_NUMBER: 209.07-att-3
TITLE: Segregation: Tier I Program Assignment Appeal Form
REFERENCE_CODE: IIB09-0002
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2015-04-30
WORD_COUNT: 143
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105946
URL: https://gps.press/sop-data/209.07-att-3/

SUMMARY:
This form allows incarcerated individuals assigned to Segregation Tier I disciplinary status to appeal their classification within 3 business days. The form documents the reason for the Tier I assignment, captures the offender's written rebuttal, and requires the Warden to review and make a final decision on whether to uphold or reverse the classification.

KEY_TOPICS: segregation, tier I program, disciplinary segregation, classification appeal, solitary confinement, offender appeal, warden review, facility discipline, case history

ATTACHMENTS:
  1. Segregation: Tier I Program 96 Hour Segregation Hearing Report
     URL: https://gps.press/sop-data/209.07-att-1/
  3. Segregation: Tier I Program Assignment Appeal Form
     URL: https://gps.press/sop-data/209.07-att-3/
  4. Tier I Program Segregation-Isolation Checklist
     URL: https://gps.press/sop-data/209.07-att-4/
  5. Segregation: Tier I Program 30 Day Review Form
     URL: https://gps.press/sop-data/209.07-att-5/
  6. Segregation: Tier I Program 30 Day Review Appeal Form
     URL: https://gps.press/sop-data/209.07-att-6/

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FULL TEXT:
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**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.**
**-------------------------------------------------------------------------------------------------------------------------------------**


**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: ____________________________**