EFTA00035915.pdf

Type: pdf
Source set: data-set-8
Extracted text

BP-A1121 
MAR 24 
U.S. DEPARTMENT OF JUSTICE 
SINGLE-CELL REVIEW FORM 
FEDERAL BUREAU OF PRISONS 
No inmate will be assigned alone in a locked cell unless there is a compelling reason and immediate approval is 
obtained from the Warden. For the duration of the inmate's single-cell status, this form is to be reviewed on day watch 
by the Unit Manager and by a Lieutenant on evening and morning watch, and weekly at the multi-disciplinary meeting. 
Inmate Name 
Security Level 
Register Number 
CIM Assignment 
Date 
Time 
Reason for 
Single Cell 
C Risk of Violence to Others: (details) 
E Severe Mental Health Problems "Disorganization": (details) 
E Other: (details) 
Unit 
Date arrived at 
Institution 
Arrival Date: 
C less than 30 days 
Index Offense 
K High Profile 
K Pretrial 
K Sex Offense 
K Other: 
MH Care Level 
K 1 K 2 
E 3 
K 4 
Medical Care Level 
K 1 K 2 
K 3 
K 4 
Psych Advisory List 
K Yes 
K No (as annotated in TRUSCOPE) 
Psych Alert 
K Yes 
K No (per review of a PP44) 
Currently 
Intoxicated 
K Yes 
K No 
I Evidence of Substance Withdrawal 
K Yes 
K No 
Alternatives 
considered 
The following employee eview for any known contraindications. Afterhours, the Lieutenant will call each employee for 
recommendations for/against single cell and note the recommendation was obtained verbally. Each employee will sign on 
the next business day. 
Employee 
Afterhours 
review 
Known 
Contraindications 
Signature 
Date 
Lieutenant 
K Yes C No 
O Yes 
O No 
Unit Manager 
C Verbal 
K Yes 
O No 
Specific Concerns 
Captain 
C Verbal 
C Yes 
O No 
Specific Concerns 
Chief Psychologist 
C Verbal 
I CI Yes 
O No 
I 
I 
Specific Concerns 
PDF 
Prescribed by P5217 & P5270 
EFTA00035915


SINGLE CELL DECISION 
Warden Signature 
Time/Date 
Decision 
El Verbal 
O Approved 
K Denied 
Rationale and Special Instructions 
A copy of this form will be maintained in Central File 
PDF 
Prescribed by P5217 & P5270 
EFTA00035916
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