SOP_NUMBER: 227.02-att-5
TITLE: Grievance Appeal to Central Office Form
REFERENCE_CODE: IIB05-0001
DIVISION: Unknown
TOPIC_AREA: 227 Policy-Facilities Conditions of Confinement
EFFECTIVE_DATE: 2019-05-10
WORD_COUNT: 198
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/105706
URL: https://gps.press/sop-data/227.02-att-5/

SUMMARY:
This form allows offenders to appeal a warden's or superintendent's response to a grievance to the central office level. Offenders must clearly state the basis for their appeal and submit the form to their counselor or grievance coordinator within the required timeframe. The form documents the offender's reasons for rejecting the initial grievance response and serves as part of the formal grievance appeal process.

KEY_TOPICS: grievance appeal, central office appeal, offender grievance, grievance form, warden response, superintendent response, inmate complaint, appeal process, grievance coordinator, counselor

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 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.