N.Y. Comp. Codes R. & Regs. tit. 7, § 1701.9
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 |
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: ______
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?
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 2/3 □ 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+ |
Form #3117
STATE OF NEW YORK - DEPARTMENT OF CORRECTIONAL SERVICES
SCREENING AND PHYSICAL ASSESSMENT FOR PLACEMENT IN A DOUBLE-CELL
D.I.N. ____ NAME: ________