BP-A1121
MAR 24

# SINGLE-CELL REVIEW FORM

# U.S. DEPARTMENT OF JUSTICE

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:<empty>
Security Level:<empty>

Register Number:<empty>
CIM Assignment:<empty>

Date:<empty>
Time:<empty>

Reason for Single Cell:
[ ] Risk of Violence to Others: (details):<empty>
[ ] Severe Mental Health Problems "Disorganization": (details):<empty>
[ ] Other: (details):<empty>

Unit:<empty>

Date arrived at Institution:
Arrival Date:<empty>
[ ] less than 30 days

Index Offense:
[ ] High Profile
[ ] Pretrial
[ ] Sex Offense
[ ] Other:

MH Care Level:
[ ] 1
[ ] 2
[ ] 3
[ ] 4

Medical Care Level:
[ ] 1
[ ] 2
[ ] 3
[ ] 4

Psych Advisory List:
[ ] Yes
[ ] No (as annotated in TRUSCOPE)

Psych Alert:
[ ] Yes
[ ] No (per review of a PP44)

Currently Intoxicated:
[ ] Yes
[ ] No
Evidence of Substance Withdrawal:
[ ] Yes
[ ] No

Alternatives considered:<empty>

# U.S. DEPARTMENT OF JUSTICE (cont.)

The following employee review 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.

<table><tr><th>Employee</th><th>Afterhours
review</th><th>Known
Contraindications</th><th>Signature</th><th>Date</th></tr><tr><td>Lieutenant</td><td>Yes No</td><td> Yes No</td><td></td><td></td></tr><tr><td>Unit Manager</td><td> Verbal</td><td> Yes  No</td><td></td><td></td></tr><tr><td>Specific Concerns</td><td colspan="4"></td></tr><tr><td>Captain</td><td>Verbal</td><td> Yes  No</td><td></td><td></td></tr><tr><td>Specific Concerns</td><td></td><td></td><td></td><td></td></tr><tr><td>Chief Psychologist</td><td>Verbal</td><td> Yes  No</td><td></td><td></td></tr><tr><td>Specific Concerns</td><td colspan="4"></td></tr></table>

PDF

Prescribed by P5217 & P5270

EFTA00037040

SINGLE CELL DECISION

Warden Signature: <empty>
Time/Date: <empty>
Decision:
[ ] Verbal
[ ] Approved
[ ] Denied

Rationale and Special Instructions: <empty>

A copy of this form will be maintained in Central File

PDF

Prescribed by P5217 & P5270

EFTA00037041