SOP 209.09-att-1: Tier III Program Assignment Request Form

SOP 209.09
Attachment 1

04/23/25
Page 1 of 2

SPECIAL MANAGEMENT UNIT: TIER III PROGRAM

OFFENDER ASSIGNMENT REQUEST FORM

I. Assignment Request

Date:
Facility:
Referring Warden:
Warden Signature:
Offender Name:
Offender GDC#:

`☐` Approved/ `☐` Disapproved

ASSIGNMENT REQUESTED FOR THE FOLLOWING REASON(S):

`☐` The offender participated in or was associated with activity such that greater management of the offender’s
interaction with other persons is necessary to ensure the safety, security, or orderly operation of GDC facilities, or
protection of the public.

`☐` Escape involving violence or serious threat of violence.

`☐` Multiple escapes or escape attempts within the previous three (3) years from a close security institution.

`☐` Participation in a major disturbance or riot during the previous five (5) years involving; (a) ten (10) or more
offenders; and/or (b) the serious threat of loss of life or actual major property damage.

`☐` Killing or causing serious injury to another person within the previous five (5) years.

`☐` Participation in a hostage taking within the previous five (5) years.

`☐` Possession of a firearm or an explosive device within the previous (5) years.

`☐` Two (2) or more disciplinary infractions for possession of a weapon within the previous five (5) years.

`☐` Three (3) or more disciplinary charges within the previous 12 months that involve excessive disruptive behavior of
either a Great or High severity level as defined in SOP 209.01, Offender Discipline.

`☐` Offender with assaultive history; or

`☐` Offender that is considered to be a person of notoriety and placement in the Tier III Program is necessary to maintain
the safety and security of a facility or the GDC system.

Describe Specific Reasons:

Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file.

SOP 209.09
Attachment 1

04/23/25
Page 2 of 2

II. Request for Emergency Placement in SMU: `☐` YES `☐` NO

Reasons for Emergency Placement in SMU:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Director, Field Operations (or designee) Decision on Emergency Placement:
`☐` APPROVED `☐` DISAPPROVED

_____________________________________________
Director, Field Operations (or designee)
Signature/Date

III. Service of Assignment Request and 48-Hr Notice of Hearing:

____________________________________ ___________________________
_Offender Signature_ _Date/Time_

**Provide offender copy of Attachment 1**

_Offender 48-Hr Hearing Rights:_

_1._ _To be served copy of Tier III Program Assignment Request Form (Attachment 1);_

_2._ _The offender has the right to attend the 48-Hr hearing. The hearing may be done by video (if the_

_offender is at another facility) or in-person (if the offender has been placed at SMU as an_

_emergency placement. The offender may forfeit this right if he or she is disruptive, and this_

_disruption shall be documented);_

_3._ _The offender has the right to make a statement and to present documents. However, the offender_

_does not have the right to call witnesses; and_

4. _The offender has the right to submit a written statement._

Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file.