SOP_NUMBER: 227.02-att-3
TITLE: Witness Statement Form
REFERENCE_CODE: IIB05-0001
DIVISION: Not specified
TOPIC_AREA: Facilities Conditions of Confinement
EFFECTIVE_DATE: 2019-05-10
WORD_COUNT: 638
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105704
URL: https://gps.press/sop-data/227.02-att-3/
SUMMARY:
This is a standardized form used by the Georgia Department of Corrections to collect sworn witness statements during investigations or grievance proceedings. The form allows witnesses (staff or inmates) to provide detailed, under-oath statements about incidents or conditions at correctional facilities. Statements must be signed, witnessed, and administered by an authorized oath administrator, with all corrections initialed by the person making the statement.
KEY_TOPICS: witness statement, sworn statement, affidavit, grievance, investigation, incident report, inmate grievance, facility investigation, witness testimony, statement form
ATTACHMENTS:
1. Offender Grievance Form
URL: https://gps.press/sop-data/227.02-att-1/
2. Staff Local Investigative Report and Recommendation Form
URL: https://gps.press/sop-data/227.02-att-2/
3. Witness Statement Form
URL: https://gps.press/sop-data/227.02-att-3/
4. Warden's/Superintendent's Grievance Response Form
URL: https://gps.press/sop-data/227.02-att-4/
5. Grievance Appeal to Central Office Form
URL: https://gps.press/sop-data/227.02-att-5/
6. Accepted_ Notification of Referral to Office of Professional Standards
URL: https://gps.press/sop-data/227.02-att-6/
7. Codes for Rejected Grievance (Formal)
URL: https://gps.press/sop-data/227.02-att-7/
8. Grievance Resolution/Drop Form (Attachment 8)
URL: https://gps.press/sop-data/227.02-att-8/
9. Central Office Appeal Response Form
URL: https://gps.press/sop-data/227.02-att-9/
10. Active Grievances Process Form
URL: https://gps.press/sop-data/227.02-att-10/
11. Warden's_Superintendent's Rejected Grievance Response
URL: https://gps.press/sop-data/227.02-att-11/
12. Rejected_ Notification of Referral to the Office of Professional Standards
URL: https://gps.press/sop-data/227.02-att-12/
13. Rejected_ Notification of Referral to the Facility ADA Coordinator
URL: https://gps.press/sop-data/227.02-att-13/
14. Accepted_ Notification of Referral to the Facility ADA Coordinator
URL: https://gps.press/sop-data/227.02-att-14/
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FULL TEXT:
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SOP 227.02
Attachment 3
5/10/19
|WITNESS STATEMENT|Col2|Col3|Col4|
|---|---|---|---|
|PLACE|DATE|TIME|FILE NUMBER
|
|LAST NAME, FIRST NAME, MIDDLE NAME|EMPLOYEE ID NUMBER|EMPLOYEE ID NUMBER|STATEIDNO.
|
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|INSTITUTION OR ADDRESS
|
|
SWORN STATEMENT|
SWORN STATEMENT|
SWORN STATEMENT|
SWORN STATEMENT|
|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
|I, __________________________________________________, WANT TO MAKE THE FOLLOWING STATEMENT UNDER OATH:
|
|EXHIBIT|INITIALS OF PERSON MAKING STATEMENT|INITIALS OF PERSON MAKING STATEMENT|
PAGE 1 OF _____ PAGES|
|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|ADDITIONAL PAGES MUST CONTAIN THE HEADING "STATEMENT OF ___ TAKEN AT___ DATED _____ CONTINUED." THE BOTTOM OF EACH
ADDITIONAL PAGE MUST BEAR THE INITIALS OF THE PERSON MAKING THE STATEMENT AND BE INITIALED AS "PAGE ___ OF ___ PAGES."
WHEN ADDITIONAL PAGES ARE UTILIZED, THE BACK OF PAGE 1 WILL BE LINED OUT, AND THE STATEMENT WILL BE CONCLUDED ON THE
REVERSE SIDE OF ANOTHER COPY OF THIS FORM.|
(Reproduced locally)
Retention Schedule: Upon Completion, this form shall be maintained with the grievance packet for four (4) years and then destroyed.
|SOP 227.02 Attachment 3 5/10/19|Col2|
|---|---|
|
STATEMENT (Continued)
|
STATEMENT (Continued)
|
|
AFFIDAVIT|
AFFIDAVIT|
|I, __________________________________________________ HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1 AND
ENDS ON PAGE ______. I FULLY UNDERSTAND THE CONDITIONS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE
INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS
STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL
INFLUENCE, OR UNLAWFUL INDUCEMENT.
____________________________________________________________
(Signature of Person Making Statement)
WITNESS
Subscribed and sworn to before me, a person authorized by law
_______________________________________________ to administer oaths, this ____ day of ___________________, 20__
_______________________________________________ at ______________________________________________________
_______________________________________________
INSTITUTION OR ADDRESS
____________________________________________________________
(Signature of Person Administering Oath)
_______________________________________________
_______________________________________________
____________________________________________________________
_______________________________________________ (Typed Name of Person Administering Oath)
INSTITUTION OR ADDRESS
____________________________________________________________
(Authority to Administer Oath)
|I, __________________________________________________ HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT WHICH BEGINS ON PAGE 1 AND
ENDS ON PAGE ______. I FULLY UNDERSTAND THE CONDITIONS OF THE ENTIRE STATEMENT MADE BY ME. THE STATEMENT IS TRUE. I HAVE
INITIALED ALL CORRECTIONS AND HAVE INITIALED THE BOTTOM OF EACH PAGE CONTAINING THE STATEMENT. I HAVE MADE THIS
STATEMENT FREELY WITHOUT HOPE OF BENEFIT OR REWARD, WITHOUT THREAT OF PUNISHMENT, AND WITHOUT COERCION, UNLAWFUL
INFLUENCE, OR UNLAWFUL INDUCEMENT.
____________________________________________________________
(Signature of Person Making Statement)
WITNESS
Subscribed and sworn to before me, a person authorized by law
_______________________________________________ to administer oaths, this ____ day of ___________________, 20__
_______________________________________________ at ______________________________________________________
_______________________________________________
INSTITUTION OR ADDRESS
____________________________________________________________
(Signature of Person Administering Oath)
_______________________________________________
_______________________________________________
____________________________________________________________
_______________________________________________ (Typed Name of Person Administering Oath)
INSTITUTION OR ADDRESS
____________________________________________________________
(Authority to Administer Oath)
|
|INITIALS OF PERSON MAKING STATEMENT|
PAGE OF PAGES
|
Retention Schedule: Upon Completion, this form shall be maintained with the grievance packet for four (4) years and then destroyed.