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>

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 | [ ] Yes [ ] No | [ ] Yes [ ] No | | |
| Unit Manager | [ ] Verbal | [ ] Yes [ ] No | | |
| Specific Concerns | | | | |
| Captain | [ ] Verbal | [ ] Yes [ ] No | | |
| Specific Concerns | | | | |
| Chief Psychologist | [ ] Verbal | [ ] Yes [ ] No | | |
| Specific Concerns | | | | |

PDF

Prescribed by P5217 & P5270

EFTA00035915

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

Rationale and Special Instructions: <empty>

A copy of this form will be maintained in Central File

PDF

Prescribed by P5217 & P5270

EFTA00035916