BP-A1121 SINGLE-CELL REVIEW FORM MAR 24 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. |inmateName | SecurityLevel | RegisterNumber [| CIMAssignment | pDate ime Reason for CZ Risk of Violence to Others: (details) Single Cell C Severe Mental Health Problems “Disorganization": (details) OC) Other: (details) Date arrived at Arrival Date: less than 30 days institution [Psych Alert | G'Yes 01 No (perreviewofaPP44) 0 Currently OYes O No Evidence of Substance Withdrawal OYes O No Intoxicated considered 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. Employee Afterhours Known Signature review Contraindications [Lieutenant | Yes) No | UYes No | pYes ONO fo Cs Specific Concerns Specific Concerns Chief Psychologist | (i Verbal |] UYes TINO PO [Captain | CiVerbal____] Yes __CINo_] Ss PDF Prescribed by P5217 & P5270 EFTA00035915

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SINGLE CELL DECISION Rationale and Special Instructions A copy of this form will be maintained in Central File PDF Prescribed by P5217 & P5270 EFTA00035916