SOP 209.08-att-3: Administrative Segregation: Tier II Program Assignment Appeal Form
Summary
Key Topics
- administrative segregation
- tier II program
- appeal process
- offender discipline
- segregation assignment
- rebuttal
- facilities director
- counselor
- case file
- classification committee
Full Text
Attachment 3
SOP 209.08 (IIB09-0003)
(04/11/16)
Administrative Segregation: Tier II Program
Assignment Appeal Form
I. Offender: ___________________________ GDC #: __________________DATE:____________
II. Administrative Segregation: Tier II Program Assignment
In accordance with Tier II Program SOP, you were placed in the Administrative Segregation: Tier II Program for the
following reasons:
_______________________________________________________________________________
_______________________________________________________________________________
III. Offender's rebuttal: (within 3 business days submit to the assigned counselor who shall forward to the Facilities
Director’s Office).
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
DATE APPEAL RECEIVED: __________________________ BY:_______________________________________(COUNSELOR)
IV. Review of Appeal
_____I concur / disagree with the Administrative Segregation: Tier II Program Classification Committee /
Warden’s Action. The following decision(s) has/have been made in this case.
___________________________________________________________________________________
_________________________________________________________________________________
_________________________________________ _______________________
Director of Field Operations/Designee Signature Date
Copies: Offender Offender File
RETENTION SCHEDULE: Upon completion of this form, it shall be placed in the offender case history file.
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OFFENDER RECEIPT FOR ADMINISTRATIVE SEGREGATION TIER II PROGRAM ASSIGNMENT
OFFENDER’S NAME: ______________________________________ I.D.#: ______________________
I ACKNOWLEDGE RECEIPT OF THIS APPEAL FROM THE ABOVE OFFENDER.
Attachment 3
SOP 209.08 (IIB09-0003)
(04/11/16)
DATE: ___/___/____ COUNSELOR’S SIGNATURE: ____________________________