SOP 220.09-att-1: Statewide Classification Committee (SCC) Referral Form

SOP 220.09
Attachment 1

7/26/19
Page 1 of 3

Statewide Classification Committee (SCC) Referral Form

FACILITY CLASSIFICATION COMMITTEE:

Offender Name: GDC# Date of Birth:

Height Weight:

Intersex : `☐` Yes `☐` No If, yes what gender does the offender identify as? `☐` Male `☐` Female

Gender: `☐` Transgender Female: Biologically male; identifies as female
`☐` Transgender Male: Biologically female; identifies as male

What pronoun does the offender prefer to be called? `☐` Female Pronouns `☐` Male Pronouns

What facility-type does the offender prefer? (Explain) `☐` Female Facility `☐` Male Facility

Medical Profiles:

Does the offender receive hormone treatments? `☐` Yes `☐` No

PREA Risk Screening Result: `☐` Victim `☐` Aggressor `☐` BOTH, Victim AND Aggressor

Has the offender ever been convicted of a sex offense? `☐` Yes (explain) `☐` No

Does the offender have a disciplinary history of a sexual nature? `☐` Yes (explain) `☐` No

Has the offender ever been convicted of a violent offense? `☐` YES (explain) `☐` No

Does the offender have a disciplinary history of assaultive behavior? `☐` Yes (explain) `☐` No

Would you recommend this offender to be placed/remain in the offender’s preferred facility type? (Explain) `☐` Yes `☐` No

Classification Chairperson (Print Name) Chairperson’s Signature Date

Warden’s Recommendation/Comments:

Warden’s Signature Date

Retention Schedule: Upon completion, this form shall become a permanent part of the offender’s institutional file.

SOP 220.09
Attachment 1

7/26/19
Page 2 of 3

SCC INTERVIEW WITH OFFENDER:

a. _Are you transgender (is your gender identity, how you feel inside, different from your assigned sex at birth)?_

- Yes - No - Declined to answer

b. _Are you intersex? (have you been told by a doctor that you have an intersex medical condition?)_

- Yes - No - Declined to answer

[NOTE: If the inmate in custody answers “YES” to Question a. or b ., ask the following:]

_1._ _What is your gender pronoun?_ - He/him/his - She/her/hers

_2._ _What is your sexual orientation (Who are you sexually attracted to)?_

- Males - Females - Both - Declined to answer

_3._ _Would you feel safer being housed in a male or female facility? (Say: we cannot guarantee your choice will be available to_

_you, but we use your choice as a factor in determining where you will be housed.)_

- Male facility □ Female facility - No preference

4. _Do you prefer underwear and hygiene products for women or men? Do you need a bra?_

- Male underwear/hygiene items □ Female underwear/hygiene items - Needs bra

5. _Do you have any concerns for your safety we should know before we decide where to house you?_

- Yes: (explain)

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- No

Interviewer’s Comments:
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_______________________________________ ________________________
Staff Signature Date

_______________________________________ _________________________
Inmate Signature Date

Retention Schedule: Upon completion, this form shall become a permanent part of the offender’s institutional file.

SOP 220.09
Attachment 1

7/26/19
Page 3 of 3

SCC HOUSING RECOMMENDATIONS:

PREA Coordinator: `☐` Remain in Current Facility Type `☐` Transfer to facility based on gender identity

Justification:

PREA Designee Signature Date

Medical Director: `☐` Remain in Current Facility Type `☐` Transfer to facility based on gender identity

Justification:

Medical Designee Signature Date

Mental Health Director: `☐` Remain in Current Facility Type `☐` Transfer to facility based on gender identity

Justification:

Mental Health Designee Signature Date

Facilities Director: `☐` Remain in Current Facility Type `☐` Transfer to facility based on gender identity

Justification:

Facilities Designee Signature Date

Assistant Commissioner: `☐` Remain in Current Facility Type `☐` Transfer to facility based on gender identity

Justification:

Assistant Commissioner, Facilities Signature Date

Retention Schedule: Upon completion, this form shall become a permanent part of the offender’s institutional file.