SOP_NUMBER: 209.07-att-4
TITLE: Tier I Program Segregation-Isolation Checklist
REFERENCE_CODE: IIB09-0002
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2015-04-30
WORD_COUNT: 276
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105947
URL: https://gps.press/sop-data/209.07-att-4/

SUMMARY:
This form is used to document and track offenders placed in Tier I Program segregation/isolation. It records offender information, daily activities including meals, showers, and exercise, observation notes, and medical or behavioral concerns during the segregation period. Staff must complete the checklist for each shift and conduct regular monitoring observations (15 or 30-minute intervals) to ensure offender safety and compliance with segregation procedures.

KEY_TOPICS: segregation, isolation, Tier I Program, segregation checklist, inmate monitoring, disciplinary confinement, cell observation, segregation isolation record, meal tracking, exercise schedule, offender supervision, 15-minute watch, 30-minute watch, segregation review

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 4**
**WARDEN/DESIGNEE'S REVIEW** **SOP IIB09-0002 (209.07)**
**AFTER DISCHARGE (SIGNATURE): ________________________** **04/30/15**
**SEGREGATION: TIER I PROGRAM ISOLATION CHECKLIST** **(Page1 of 2)**

**OFFENDER NAME: ___________________________________________ GDC ID: ____________________ RACE: ___________**
**PRIOR LIVING UNIT: __________ COUNSELOR: ______________________________ PRIOR JOB DETAIL______________**
**DATE COMMITTED: __________________ EXPECTED DISCHARGE DATE: _____________________ STATUS: _________**
**TIME COMMITTED: ____________ ACTUAL DISCHARGE DATE & TIME: ________________________________________**
**REASON FOR ASSIGNMENT: ________________________________________________________________________________**
**____________________________________________________________________________________________________________**
**PERTINENT INFORMATION:____________________________________________________________________**
















|Date|Shift|Meals|Col4|Col5|SH|EXER|COMMENTS<br>(Include note/sig. of staff<br>visits, such as medical)|ADM<br>REV:|OFFICER<br>SIG:|
|---|---|---|---|---|---|---|---|---|---|
|<br> <br>**Date**<br>|<br> <br>**Shift**<br>|**B **|**L **|**S **|**S **|**S **|**S **|**S **|**S **|
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**EXPLANATORY NOTES: Meals - Yes(Y) or No(N) or Refused(R); Shower(SH) - Same codes as meals; Exercise (Exer) - Enter actual time period (e.g. 9:15AM -**
**10:30AM Inside)**
**PERTINENT INFORMATION: Epileptic, Diabetic, Religious Diet, Suicidal, Assaultive, etc.**

**COMMENTS:General conduct, attitude, hygiene, sanitation of cell,(continue on back if needed).**

**SEGREGATION REVIEW: Asst. Warden or Duty Officer, shift OIC/Captain, as appropriate**


**SEGREGATION: TIER I PROGRAM ISOLATION CHECKLIST** **Attachment 4**
**30-MINUTE OR 15-MINUTE WATCH** **SOP IIB09-0002 (209.07)**

|Col1|Col2|Col3|Col4|Segregation|Col6|n/Isolation Observation|Col8|n Record|Col10|Col11|Col12|04/30/15 Page 2 of 2|Col14|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|<br>**DATE**|
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|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|<br>TIME/INITIALS|
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**Copy: Offender File**
**RETENTION SCHEDULE: Upon completion of this form, it will be placed in the offender’s//probationer’s case history file.**