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.
Inmate Name Security Level
Register Number CIM Assignment
Date Time
Reason for C Risk of Violence to Others: (details)
Single Cell
E Severe Mental Health Problems "Disorganization": (details)
E Other: (details)
Unit
Date arrived at Arrival Date: C less than 30 days
Institution
Index Offense ❑ High Profile ❑ Pretrial ❑ Sex Offense ❑ Other:
MH Care Level ❑1 ❑2 E3 ❑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 ❑ Yes ❑ No I Evidence of Substance Withdrawal ❑ Yes ❑ No
Intoxicated
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 Known Signature Date
review Contraindications
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