Attachment J-7 Monthly Program Activity Report.pdf
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- Solicitation number
- 9594CS26Q0004
About this file
This is a Monthly Program Activity Report template (Attachment J-7) used by contractors to report performance metrics for CSOSA (Court Services and Offender Supervision Agency) treatment programs.
The report requires contractors to submit monthly activity data organized into six primary sections. Table 1 and Table 3 track case statistics for non-RSC (Residential Service Center) and RSC cases respectively, capturing active cases, scheduled placements, no-shows, actual admissions, and detailed discharge categories including successful completions (with percentages), non-compliance discharges, dropouts against clinical advice, absconded cases, rearrested/remanded individuals, medical/hospitalized cases, administrative discharges, and cases where supervision periods ended. Tables 2 and 4 require specific identification of individuals by name and PDID number for admitted clients, no-shows, successful completions, and unsuccessful completions, with discharge reports required for unsuccessful completions. Table 5 documents monthly staff changes, requiring submission of medical clearances, resumes, licenses, and certifications for new hires along with position titles, hire dates, and security clearance submission dates, plus separation information for resignations or terminations. Table 6 addresses unusual incidents, requiring the total count of incident reports submitted to CSOSA with dates, categorized by incident type including death, abuse, fire, theft, property destruction, patient criminal charges, disease outbreaks, inappropriate staff relationships, and chronic complaints. Additionally, contractors must provide a narrative describing any serious facility maintenance problems encountered during the month.
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Attachment J-7
Monthly Program Activity Report
Contractor Name:__________________________________Contract
Number:_________________
Program Address:______________________________________________________________
Treatment Modality:____________________________________________________________
Submitted By:_____________________________ Telephone Number:___________________
PERFORMANCE TARGETS
For the Month of __________________ Year___________
Instructions: Please complete the numbers and names required for the below tables. Attach additional pages if necessary.
TABLE 1 (Non- RSC Cases)
A. Total Number of active cases at the end of the previous month
B. Total Scheduled Placements No Shows Actual Admissions
C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended
Total number of active cases at the end of the month
TABLE 2 (Non-RSC Cases):
Please include the names and PDID numbers of individuals for each category
ADMITTED NO-SHOWS SUCCESSFUL
COMPLETIONS
UNSUCCESSFUL
COMPLETIONS
(Please attach discharge reports for each name listed below)
TABLE 3 (RSC Cases)
A. Total Number of active cases at the end of the previous month
B. Total Scheduled Placements No Shows Actual Admissions
C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended
Total number of active cases at the end of the month
TABLE 4 (RSC Cases):
Please include the names and PDID numbers of individuals for each category
ADMITTED NO-SHOWS SUCCESSFUL
COMPLETIONS
UNSUCCESSFUL
COMPLETIONS
(Please attach discharge reports for each name listed below)
TABLE 5: Monthly CSOSA Contract Staff Changes
New Hires Name (Please attach the medical clearance, resumes, licenses and certifications)
Position Title Hire Date
Security Clearance Submission Date
Resignations or Terminations
Position Title Separation Date
TABLE 6: Unusual Incidents Please attach copies of all incident reports (via secured email method) to this monthly report.
A. Total Number of unusual incident reports for the month: ______________
Date of incident
Date report was submitted to
CSOSA
B. Type(s) of unusual incidents for the month.
Death, serious illness, injury or incapacitation Physical, sexual or verbal abuse of an Patient by staff or others Fire Theft Destruction of loss of property, or sudden/serious problems in the facility Patient criminal charges, arrest, or incarceration Infestations or outbreak of communicable disease Inappropriate relationships/fraternization between an Patient and contract staff Chronic complaints from Patient’s families or Patients themselves
Monthly Physical Plant Issues (Provide narrative, describing all serious facility maintenance problems):
File details come from the government source that posted it. Updated .