Sec. 1701.9. Forms

Form #3117

STATE OF NEW YORK - DEPARTMENT OF CORRECTIONAL SERVICES

SCREENING AND PHYSICAL ASSESSMENT FOR PLACEMENT IN A DOUBLE-CELL

D.I.N. ____ NAME: ________

I. Medical Record Screening Review

A. Has the person been diagnosed to have any of the following communicable illnesses that are currently contagious?

□ Amebiasis	□ Diptheria	□ Lymphogranuloma	□ Rubella
□ Chancroid	□ E. coli 0157:H7	venereum	□ Salmonellosis
□ Chickenpox/Herpes	□ Encephalitis	□ Measles	□ Shigellosis
Zoster	□ Giardiasis	□ Meningitis	□ Syphilis
□ Chlamydia trachomatis	□ Gonococcal Infection	□ Meningococcemia	□ Tuberculosis
□ Cholera	□ Hepatitis	□ Mumps	□ Typhoid
□ Crytosporidiosis		□ Pertussis	□ Yersiniosis
		□ Plague

B. Has the person been noted to currently have symptoms that indicate an acute illness which could be contagious at this time? □ No □ Yes If so, please specify these symptoms:

C. Are there known medical contraindications to him being placed in a double-cell? (e.g., any conditions noted in I-A or B above or chronic debilitating disease, skin lesions, open sores, cardiac condition-stage 4) □ No □ Yes (single-cell)

D. Are there any known medical indications requiring him or her to be placed in a bottom bunk bed? (e.g., medically documented - back problems {through radiologic or surgical physician review}, medication for seizure disorder, diabetes/insulin dependent, age over 60 years, permanent physical disability {e.g., amputee, rheumatoid arthritis}, diagnosis of sleep apnea, current acute injury or serious medical conditions {e.g., fractures, recent MI, advanced arthritis}) □ No □ Yes (bottom bunk)

 

Report answers to C. and

 

D. to the DSS or

 

designee immediately.

Signed: ________ Date: ______

 

II. Physical Assessment (A physical assessment as indicated below must be conducted prior to or within 48 hours of placement in a double-cell.)

A. Based upon your physical assessment of the person, does he or she:

□ No □ Yes Appear acutely ill?

□ No □ Yes Have evidence of persistent cough?

□ No □ Yes Currently have severe diarrhea?

□ No □ Yes Have respiratory check sounds that could indicate an acutely communicable illness?

□ No □ Yes Have skin rashes, jaundice or lesions that could indicate an acutely communicable illness?

B. From your physical assessment of this person, are there medical contraindications to him being placed in a double-cell? (e.g., any conditions noted in Part II. A.) □ No □ Yes (single-cell)

C. From your physical assessment of this person, are there medical indications requiring him to be placed in a bottom bunk bed? □ No □ Yes (bottom bunk)

 

Report answer to B. to

 

the DSS or designee

 

immediately.

Signed: ________ Date: ______

Rev. 6/16

Form #2201

STATE OF NEW YORK - DEPARTMENT OF CORRECTIONAL SERVICES

DOUBLE-CELL INFORMATION SHEET

 

CORRECTIONAL FACILITY

D.I.N.

 

NAME:

 

D.O.B.

 

DATE:

 

I. SUITABILITY History and Behavior

□ No □ Yes Victim Prone

 

□ No □ Yes Assaultive

 

□ No □ Yes Enemies (at facility)

 

□ No □ Yes Homicidal

 

□ No □ Yes Same Gender Sexual Violence □ No □ Yes Extremely violent nature of the instant offense or criminal history

"Yes" in any above category requires override reason prior to affirmative double cell recommendation.

Reason for Override

 

□ No □ Yes Has the inmate been with DOCS for at least 24 months? □ No □ Yes Has the inmate remained free of Tier II or III convictions within the last 24 months?

□ No □ Yes Has the inmate volunteered for double-cell housing?

If "Yes" in all of the above categories, the inmate is currently ineligible for double-celling.

□ No □ Yes Is the inmate over 6′5″, over 299 lbs.? If "yes" do not double-cell.

□ No □ Yes Is the inmate 70 years of age or older? If “yes” do not double-cell, unless inmate volunteered.

 

Health Services Review Results

□ Approved

 

□ Disapproved

 

Date: ____ □ bottom bunk only

 

Mental Health Status

OMH Level 1

 

□ No □ Yes

If "Yes" inmate may not be double celled.

OMH Level

/₃

 

□ No □ Yes

 

□ Approved

 

□ Disapproved

Comments:

 

 

D.S.S. (or designee) Review: □ APPROVED

 

□ DISAPPROVED

Comments:

 

Signature

________

Date

_____

 

II. COMPATIBILITY CELL _ _ --_ _--_ _ _

CANDIDATE _ _ - _ - _ _ _ _		CURRENTLY ASSIGNED _ _ - _ - _ _ _ _
Age	Race	Age	Race
□ 16-21	□ Black	□ 16-21	□ Black
□ 22-35	□ Hispanic	□ 22-35	□ Hispanic
□ 36-59	□ White	□ 36-59	□ White
□ 60+ bottom bunk	□ Other	□ 60+ bottom bunk	□ Other
Language	Religion	Language	Religion
□ English	□ Christian	□ English	□ Christian
□ Spanish Only	□ Muslim	□ Spanish Only	□ Muslim
□ Other _____	□ Jewish	□ Other	□ Jewish
	□ Other _____		□ Other
Years to E.R. D.	Size	Years to E.R. D.	Size
□ less than 3	□ less than 150 lbs	□ less than 3	□ less than 150 lbs
□ 3-8	□ 150-260	□ 3-8	□ 150-260
□ 9-15	□ 261-299	□ 9-15	□ 261-299
□ 16+		□ 16+

Rev. 4/18