Segregation Referral

IE) 7
NISQUALLY PUBLIC SAFETY COMPLEX

SEGREGATION REFERRAL

INMATE NAME: VQIM
DATE AGENCY NUMBER[Placed in segregation] DATE: TIME: limp
INCIDENT REPORT NUMBER: 

USE OF FORCE INVOLVED: YES No - 

SEGREGATION STATUS

ADMINISTRATIVE-PENDING HEARING I
ADM ISTRATIVE-ME DICAL (MEDICAL STAFF SIGNATURE AND COMMENT REQUIRED) 
ADMINISTRATIVE-PROTECTIVE CUSTODY 


Record below, a brief outline of the circumstances leading to placement in Administrative
Segregation.

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ADMITTED BY:  RANK: g-?-I?Qy

MEDICAL COMMENT:

 

 

 

 

 

 

MEDICAL STAFF: DATE TIME:

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