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s in a special housing status? Is there an additional assessment for every cne month interval thereafter? O Yes. O No dn.. why not? O Yes O No Acton taken on the above date by the Segregation Review ()Moat or the Reviewing Authority: K Re:eased from Special Housing. O Continue in Special Reusing

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n a special hOuSelg status? K Yes: K No Is there an addmonal assessment for every one month interval thereafter? K Yes: K No if no. why not? Acton taken on the above date by the Segregation Review Official or the Reviewing Authority: K Released from Special Housing: K Conbnue vi Special Housin

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