SOP_NUMBER: 209.07-att-6
TITLE: Segregation: Tier I Program 30 Day Review Appeal Form
REFERENCE_CODE: IIB09-0002
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2015-04-30
WORD_COUNT: 139
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105949
URL: https://gps.press/sop-data/209.07-att-6/

SUMMARY:
This form allows inmates in the Tier I segregation program to appeal the results of their 30-day review classification decision. Inmates have three business days to submit a written rebuttal to their assigned counselor, who forwards it to the Warden. The Warden then reviews the appeal and issues a final decision on whether to concur or disagree with the Segregation: Tier I Program Classification Committee's original action.

KEY_TOPICS: segregation, Tier I program, 30 day review, appeal, classification, disciplinary segregation, inmate appeal, Warden review, rebuttal, administrative segregation

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 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:**
**_______________________________________________________________________________**

**_______________________________________________________________________________**

**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: ____________________________**