EFTA00110621 BP-A295.052 APRIL 1994 SPECIAL HOUSING UNIT REVIEW DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS
Inmate Name:Register Number:Unit:7Institution:NEW YORK MCC
Date Entered Special Housing:07-16-2019Reason for Placement:PENDING SIS INVESTIGATION/THREAT ASSESSMENT
I. Subject:(2 or 3 Days)3 Day ReviewDate Reviewed07-19-2019
Action Taken on the Above Date:Continue In Special Housing Unit
Printed Name/Signature:
II. RECORD REVIEW. (To be done weekly in the absence, beginning after the in-person 7 day review, and continuing every week between each in-person 30 day review.)
DATEACTION TAKENREMARKSSIGNATURE
07-23-2019Continue in Special Housing Unit
III. Subject: (7 or 30 Days)
7 Day Review		Review By (SRO):Reviewing Authority:
Date inmate appeared for a Special Housing Review:
07-23-2019		Or Date inmate waived right to appear:
Has been seen daily by Medical Staff: ☑ Yes; □ No
Has been seen daily by responsible officer designated by Warden: ☑ Yes; □ No
Has received prescribed weekly exercise: ☑ Yes; □ No
Proper documentation and justification in the Central File (Incident Report, DHO Report, copies of Special Housing Review Form): ☑ Yes; □ No
if no, why not?
Is there a written psychiatric or psychological assessment on the inmate who has spent 30 days in a special housing status? ☑ Yes; □ No
Is there an additional assessment for every one month interval thereafter? ☑ Yes; □ No
if no, why not?
Action taken on the above date by the Segregation Review Official or the Reviewing Authority:
☐ Released from Special Housing; ☑ Continue in Special Housing
Did inmate in Administrative Detention receive a written copy of decision and the basis for the finding at each 30 day review? ☑ Yes; □ No
if no, why not (Should be given provided institutional security not compromised)?
Remarks: (Any change in the reason for placement is to be noted in this section. If the reason for placement changes, the inmate must receive a copy of this form):
Date of Next Review:
07-30-2019
Printed Name and Signature of Segregation Review Official or the Reviewing Authority and Date Signed:
Record Copy - Central File This form replaces BP-295(52) dated January 1988 Page 1 of 1 7/23/2019