SOP 209.08-att-7: Administrative Segregation: Tier II Program 90 Day Review Assignment Appeal Form

Attachment 7
SOP 209.08 (IIB09-0003)

(04/11/16)

Administrative Segregation: Tier II Program
90 Day Review Assignment Appeal Form

I. Offender: ___________________________ GDC #: __________________ DATE:____________

II. Administrative Segregation: Tier II Program Assignment

In accordance with Administrative Segregation: Tier II Program SOP, a 90 Day Review was conducted with the
following recommendation:
_______________________________________________________________________________

_______________________________________________________________________________

III. Offender's rebuttal: (within 3 business days submit to the assigned counselor who shall forward to the Warden).

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

DATE APPEAL RECEIVED: ________________________ BY:_________________________________________(COUNSELOR)

IV. Review of Appeal

_____I concur / disagree with the Administrative Segregation: Tier II 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 shall be placed in the offender’s 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.

DATE: ___/___/____ COUNSELOR’S SIGNATURE: ____________________________