SOP 227.02-att-5: Grievance Appeal to Central Office Form
Summary
Key Topics
- grievance appeal
- central office appeal
- offender grievance
- grievance form
- warden response
- superintendent response
- inmate complaint
- appeal process
- grievance coordinator
- counselor
Full Text
SOP 227.02
Attachment 5
5/10/19
DATE APPEAL RECEIVED FROM OFFENDER_________________________________________
GRIEVANCE APPEAL FORM
______________________ _____________ ____________________
OFFENDER NAME I.D. NUMBER GRIEVANCE NUMBER
I reject the Warden's/Superintendent's response to my grievance. The basis for this appeal is as
follows:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NOTE: The option to appeal a proposed resolution rests with the grievant. All grievances indicating a desire for appeal
will be forwarded to the next level. However, to allow a full review of all issues the grievant wishes considered, he or
she should state these reasons clearly in the appeal. Statements such as "not satisfied" or "appeal further" will result only
in a general review. If for some reason this appeal is being submitted later than the allotted time frame, please
state clearly the reasons why if you wish for this appeal to be considered. This appeal form along with the
Grievance Form must be submitted to your Counselor or Grievance Coordinator.
# OFFENDERS'S SIGNATURE: ______________________________________DATE: --------------------------------------------------------------------------------------------------------------
RECEIPT FOR GRIEVANCE AT COUNSELOR’S LEVEL
OFFENDER’S NAME: I.D.#
I ACKNOWLEDGE RECEIPT OF GRIEVANCE APPEAL NUMBER FROM THE ABOVE
OFFENDER.
DATE: / / COUNSELOR’S SIGNATURE:
(Reproduced locally)
Retention Schedule: Upon Completion, this form shall be maintained with the grievance packet for four (4) years and then destroyed.