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 ❑ High Profile ❑ Pretrial ❑ Sex Offense ❑ Other: MH Care Level ❑ 1 ❑ 2 E 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 I Evidence of Substance Withdrawal ❑ Yes ❑ 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 ❑ Yes C No O Yes O No Unit Manager C Verbal ❑ 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 ❑ Denied Rationale and Special Instructions A copy of this form will be maintained in Central File PDF Prescribed by P5217 & P5270 EFTA00035916