SOP_NUMBER: 209.08-att-3
TITLE: Administrative Segregation: Tier II Program Assignment Appeal Form
REFERENCE_CODE: IIB09-0003
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2016-04-11
WORD_COUNT: 160
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105956
URL: https://gps.press/sop-data/209.08-att-3/

SUMMARY:
This form allows offenders placed in Administrative Segregation Tier II Program to submit a written appeal challenging their assignment within three business days. The form documents the reasons for placement, allows the offender to present a rebuttal, and provides space for the Director of Field Operations or designee to review and make a final determination on the appeal. The completed form is retained in the offender's case history file.

KEY_TOPICS: administrative segregation, tier II program, appeal process, offender discipline, segregation assignment, rebuttal, facilities director, counselor, case file, classification committee

ATTACHMENTS:
  1. Tier II Program Assignment Recommendation and 1Initial Segregation Review
     URL: https://gps.press/sop-data/209.08-att-1/
  2. Administrative Segregation: Tier II Program Assignment Memo
     URL: https://gps.press/sop-data/209.08-att-2/
  3. Administrative Segregation: Tier II Program Assignment Appeal Form
     URL: https://gps.press/sop-data/209.08-att-3/
  4. Administration Segregation: Tier II Program Handout
     URL: https://gps.press/sop-data/209.08-att-4/
  5. Administrative Segregation: Tier II Program 90-Day Review
     URL: https://gps.press/sop-data/209.08-att-5/
  7. Administrative Segregation: Tier II Program 90 Day Review Assignment Appeal Form
     URL: https://gps.press/sop-data/209.08-att-7/
  8. Administrative Segregation: Tier II Program - Cell Check Sheet
     URL: https://gps.press/sop-data/209.08-att-8/
  9. Administrative Segregation: Tier II Program Checklist
     URL: https://gps.press/sop-data/209.08-att-9/
  10. Administrative Segregation: Tier II Program Checklist - 30-Minute and 15-Minute Watch Form/Observation Record
     URL: https://gps.press/sop-data/209.08-att-10/
  11. Administrative Segregation: Tier II Program Performance Recording Sheet
     URL: https://gps.press/sop-data/209.08-att-11/

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

**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: ____________________________**