SOP_NUMBER: 209.08-att-9
TITLE: Administrative Segregation: Tier II Program Checklist
REFERENCE_CODE: IIB09-0003
DIVISION: Facilities
TOPIC_AREA: 209 Policy-Facilities Control/Discipline/Segregation
EFFECTIVE_DATE: 2016-04-11
WORD_COUNT: 212
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105962
URL: https://gps.press/sop-data/209.08-att-9/

SUMMARY:
This is a daily monitoring and documentation form used to track offenders assigned to Tier II Administrative Segregation. Staff complete the checklist to record meal service, shower access, exercise, cell sanitation, and other observations during each shift. The form requires administrative review and is placed in the offender's case file upon completion of the segregation assignment.

KEY_TOPICS: administrative segregation, Tier II program, segregation monitoring, disciplinary housing, offender tracking, meals in segregation, exercise time, shower access, cell sanitation, segregation checklist, behavioral documentation, warden review, offender case file

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/

========================================================================
FULL TEXT:
========================================================================

**Attachment 9**
**WARDEN/DESIGNEE'S REVIEW** **SOP 209.08 (IIB09-0003)**
**AFTER DISCHARGE (SIGN :) ________________________** **(04/11/16)**

**ADMINISTRATIVE SEGREGATION: TIER II PROGRAM CHECKLIST**

**OFFENDER NAME: ___________________________________________ GDC #: ____________________ RACE: ___________**
**PRIOR LIVING UNIT: __________ COUNSELOR: ______________________________**
**DATE COMMITTED: __________________ EXPECTED DISCHARGE DATE: _____________________**
**TIME COMMITTED: ____________ ACTUAL DISCHARGE DATE & TIME: ________________________________________**
**REASON FOR ASSIGNMENT: ________________________________________________________________________________**
**PERTINENT INFORMATION_________________________________________________________________________________**


**STATUS CHANGE**

**DATE COMMITTED: _________________EXPECTED DISCHARGE DATE_____________________STATUS___________**
**TIME COMMITTED__________________ACTUAL DISCHARGE DATE &TIME___________________________**
**___________________________________________________________________________________________________________**

**PERTINENT INFORMATION: ____________________________________________________________________**



















|Date|Shift|Meals|Col4|Col5|SH|EXER|CELL<br>SANT|COMMENTS<br>(Include note/sig. of staff<br>visits, such as medical)|ADM<br>REV:|OFFICER<br>SIG:|
|---|---|---|---|---|---|---|---|---|---|---|
|<br> <br>**Date**<br>|<br> <br>**Shift**<br>|**B **|**L **|**S **|**S **|**S **|**S **|**S **|**S **|**S **|
|<br>**MON.**|**1st**||||||||||
|<br>**MON.**|**2nd**||||||||||
|<br>**TUES.**|**1st**||||||||||
|<br>**TUES.**|**2nd**||||||||||
|<br>**WED.**|**1st**||||||||||
|<br>**WED.**|**2nd**||||||||||
|<br>**THURS.**|**1st**||||||||||
|<br>**THURS.**|**2nd**||||||||||
|<br>**FRI.**|**1st**||||||||||
|<br>**FRI.**|**2nd**||||||||||
|<br>**SAT.**|**1st**||||||||||
|<br>**SAT.**|**2nd**||||||||||
|<br>**SUN.**|**1st**||||||||||
|<br>**SUN.**|**2nd**||||||||||


**EXPLANATORY NOTES: Meals - Yes(Y) or No(N) or Refused(R); Shower(SH) - Same codes as meals; Exercise (Exer) - Enter actual time period (e.g. 9:15AM -**
**10:30AM Inside)**
**PERTINENT INFORMATION: Epileptic, Diabetic, Religious Diet, Suicidal, Assaultive, etc.**
**COMMENTS: General conduct, attitude, hygiene, sanitation of cell,(continue on back if needed).**
**ADMINISTRATIVE REVIEW: Deputy Warden or Duty Officer, shift OIC/Captain, as appropriate**

**Copies:** **Offender File**
**RETENTION SCHEDULE:  Upon completion of this form, it shall be placed in the offender’s case history file.**