SOP 209.55-att-3: Special Management Unit – Tier III Segregated Transition Education Program (Tier III STEP) 30 Day Review Appeal Form

Attachment 3

SOP 209.55

04/25/19

Special Management Unit – Tier III Segregated Transition Education Program (Tier III STEP)

30 Day Review Appeal Form

I. Offender: _________________________ GDC #: __________________

Phase: __________ Bed Assignment__________ Date _____________

II. Appeal of 30-Day Review Hearing

I wish to appeal the decision of the Tier III STEP Classification Committee regarding my 30-Day
Review:

REASON FOR APPEAL (submit to the assigned counselor within three (3) Business Days from date of
receipt of final 30-Day Review Hearing Form (Attachment 2). Assigned counselor shall forward to the
Warden).
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

______________________________ _________________
Offender’s Signature Date

Date appeal received: ______________ By: _____________________________(COUNSELOR)

Offender Acknowledgment Appeal Received by Counselor: _____________________________
_Signature/Date_
Date Appeal Sent to Warden: ____________________ _(Send within 3 calendar days of receipt of Appeal)_

III. Warden’s Review

Warden’s Receipt of Appeal: _____________________ Warden’s Decision on Appeal:

I concur / disagree with the Tier III STEP Classification Committee's 30-Day Review and the
following recommendation(s) has been made in this case:

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________ _________________
Warden Date

IV. Offender Acknowledgment of Appeal: ____________________________________

_Signature/Date_

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