SOP 209.07-att-6: Segregation: Tier I Program 30 Day Review Appeal Form
Summary
Key Topics
- segregation
- Tier I program
- 30 day review
- appeal
- classification
- disciplinary segregation
- inmate appeal
- Warden review
- rebuttal
- administrative segregation
Full Text
Attachment 6
SOP IIB09-0002 (209.07)
04/30/15
SEGREGATION: TIER I PROGRAM
30 Day Review Appeal Form
I. Offender: ___________________________ GDC #: __________________ DATE: _____________
II. Segregation 30 Day Review Appeal
In accordance with Segregation: Tier I SOP, a 30 Day Review was conducted with the following recommendation:
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III. Offender's rebuttal: (within 3 business days submit to the assigned counselor who will forward to the Warden)
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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.
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___________________________ _______________________
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: ____________________________