## SINGLE-CELL REVIEW FORM

## BP-A1121 MAR 24 U.S. DEPARTMENT OF JUSTICE

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<br>Single Cell      | C Risk of Violence to Others: (details)                      |                                    |               |  |  |
|                                | E Severe Mental Health Problems "Disorganization": (details) |                                    |               |  |  |
|                                | E Other: (details)                                           |                                    |               |  |  |
| Unit                           |                                                              |                                    |               |  |  |
| Date arrived at<br>Institution | C less than 30 days<br>Arrival Date:                         |                                    |               |  |  |
| Index Offense                  | ❑ High Profile<br>❑ Pretrial                                 | ❑ Sex Offense<br>❑ Other:          |               |  |  |
| MH Care Level                  | E 3<br>❑ 1<br>❑ 2<br>❑ 4                                     |                                    |               |  |  |
| Medical Care Level             | ❑ 1<br>❑ 2<br>❑ 4<br>❑ 3                                     |                                    |               |  |  |
| Psych Advisory List            | ❑ Yes<br>❑ No (as annotated in TRUSCOPE)                     |                                    |               |  |  |
| Psych Alert                    | ❑ Yes<br>❑ No (per review of a PP44)                         |                                    |               |  |  |
| Currently<br>Intoxicated       | ❑ Yes<br>❑ No                                                | I Evidence of Substance Withdrawal | ❑ Yes<br>❑ No |  |  |
| Alternatives<br>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<br>review | Known<br>Contraindications | Signature | Date |
|--------------------|----------------------|----------------------------|-----------|------|
| Lieutenant         | ❑ Yes C No           | O Yes<br>O No              |           |      |
| Unit Manager       | C Verbal             | ❑ Yes<br>O No              |           |      |
| Specific Concerns  |                      |                            |           |      |
| Captain            | C Verbal             | C Yes<br>O No              |           |      |
| Specific Concerns  |                      |                            |           |      |
| Chief Psychologist | C Verbal             | I CI Yes<br>O No           | I         | I    |
| Specific Concerns  |                      |                            |           |      |

| SINGLE CELL DECISION                                   |           |            |          |  |  |  |
|--------------------------------------------------------|-----------|------------|----------|--|--|--|
| Warden Signature                                       | Time/Date | Decision   |          |  |  |  |
|                                                        | El Verbal | O Approved | ❑ Denied |  |  |  |
|                                                        |           |            |          |  |  |  |
| Rationale and Special Instructions                     |           |            |          |  |  |  |
|                                                        |           |            |          |  |  |  |
|                                                        |           |            |          |  |  |  |
| A copy of this form will be maintained in Central File |           |            |          |  |  |  |
|                                                        |           |            |          |  |  |  |