SOP 209.11-att-7: RHA-JOAS Program 30 Day Review_Assignment Appeal Form

Attachment 7

SOP 209.11

(04/11/16)

Restrictive Housing Assignment - Juvenile Offender Administrative Segregation

30 Day Review Appeal Form

I. Juvenile Offender: __________________________GDC#:__________________ DATE: ____________

II. Restrictive Housing Assignment - Juvenile Offender Administrative Segregation Assignment:

In accordance with Restrictive Housing Assignment - Juvenile Offender Administrative Segregation SOP, a 30 Day
Review was conducted with the following recommendation:
_______________________________________________________________________________

_______________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

DATE APPEAL RECEIVED: ________________________ BY:_________________________________________(COUNSELOR)

IV. Review of Appeal:

_____I concur / disagree with the Restrictive Housing Assignment - Juvenile Offender Administrative
Segregation Program Classification Committee’s Action. The following decision(s) has/have been made in this case:

___________________________________________________________________________________

_________________________________________________________________________________

___________________________ _______________________
Warden’s Signature Date

Copies: Offender
RETENTION SCHEDULE: Upon completion of this form, it shall be placed in the juvenile offender’s case history file.
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OFFENDER RECEIPT FOR RESTRICTIVE HOUSING ASSIGNMENT - JUVENILE OFFENDER ADMINISTRATIVE
SEGREGATION PROGRAM ASSIGNMENT

JUVENILE OFFENDER’S NAME: ______________________________________ I.D. #: ______________________

I ACKNOWLEDGE RECEIPT OF THIS APPEAL FROM THE ABOVE OFFENDER.

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

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