DOC Form OP-040204 Attachment D "Individual Offender Segregation Log" - Oklahoma

Form OP-040204 is a Oklahoma Department of Corrections form also known as the "Attachment D - Individual Offender Segregation Log". The latest edition of the form was released in March 1, 2013 and is available for digital filing.

Download a PDF version of the Form OP-040204 down below or find it on Oklahoma Department of Corrections Forms website.

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Download DOC Form OP-040204 Attachment D "Individual Offender Segregation Log" - Oklahoma

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Attachment D
OP-040204
Individual Offender Segregation Log
Name:
DOC#
Custody Status/Date:
Date /Time Received:
Authorizing Official
Change/Date:
Date /Time Released:
Authorizing Official
Change/Date:
Disciplinary Seg. (#Days):
Cell #
Mattress and Pillow Sanitized/Issued
Include Appropriate Information and Abbreviation in Each Box
R-Refused X-Received
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Activity
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Medical Services Visit 4-4258
(Other than Pill Call)
Mental Health Services Visit
4-4256 (Social Services 4-4273)
Prescribed Medication 4-4261
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
Meals Served 4-4320
Exercise (1hr, 5 Days) 4-4270
Canteen (Hygiene Items and
Writing Materials Only) 4-4261,
4-4273
Shave/Shower (3 Per Wk.)
4-4262
Hygiene/ Indigent Items
Telephone Privileges 4-4271, 4-
4272
Clothing Exchange 4-4263
Laundry Exchange (Sheet,
Blanket, Pillows) 4-4263
Mail Sent/Received 4-4266
Leisure Library / Reading
Materials 4-4269, 4-4273
Barbering/Hair Care Services
4-4263
Educational Services 4-4258, 4-
4273
Recreational Services 4-4273
Law Library Services / Visit
4-4268, 4-4273
Legal Visit / Calls 4-4272
Religious Guidance Visit
(Counseling) 4-4258, 4-4273
Staff Visit (Unit / Admin.) 4-4273
Visits 4-4267, 4-4498
Shift Supervisor/Ofc. in charge
of unit (once daily visit with
offender) 4-4258
Cell inspections and shakedowns will be recorded as defined in facility post orders.
(R 3/13)
Attachment D
OP-040204
Individual Offender Segregation Log
Name:
DOC#
Custody Status/Date:
Date /Time Received:
Authorizing Official
Change/Date:
Date /Time Released:
Authorizing Official
Change/Date:
Disciplinary Seg. (#Days):
Cell #
Mattress and Pillow Sanitized/Issued
Include Appropriate Information and Abbreviation in Each Box
R-Refused X-Received
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Activity
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Medical Services Visit 4-4258
(Other than Pill Call)
Mental Health Services Visit
4-4256 (Social Services 4-4273)
Prescribed Medication 4-4261
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
B
L
D
Meals Served 4-4320
Exercise (1hr, 5 Days) 4-4270
Canteen (Hygiene Items and
Writing Materials Only) 4-4261,
4-4273
Shave/Shower (3 Per Wk.)
4-4262
Hygiene/ Indigent Items
Telephone Privileges 4-4271, 4-
4272
Clothing Exchange 4-4263
Laundry Exchange (Sheet,
Blanket, Pillows) 4-4263
Mail Sent/Received 4-4266
Leisure Library / Reading
Materials 4-4269, 4-4273
Barbering/Hair Care Services
4-4263
Educational Services 4-4258, 4-
4273
Recreational Services 4-4273
Law Library Services / Visit
4-4268, 4-4273
Legal Visit / Calls 4-4272
Religious Guidance Visit
(Counseling) 4-4258, 4-4273
Staff Visit (Unit / Admin.) 4-4273
Visits 4-4267, 4-4498
Shift Supervisor/Ofc. in charge
of unit (once daily visit with
offender) 4-4258
Cell inspections and shakedowns will be recorded as defined in facility post orders.
(R 3/13)
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