Attachment J-9 Monthly Program Activity Report.docx
DOCX document 28 KB Posted
- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a monthly program activity report template designed for contractors providing residential drug treatment services to the Court Services and Offender Supervision Agency (CSOSA). The form serves as an appendix document (Attachment J-9) to contract solicitation 9594CS26Q0055 for residential drug treatment services for detained offenders.
The template requires contractors to submit monthly performance data including active case counts, scheduled placements, admission numbers, discharge statistics (broken down by successful completions, unsuccessful completions, non-compliance, dropouts, absconding, re-arrest, medical issues, and administrative closure), and staff roster changes with supporting documentation such as medical clearances, resumes, licenses, and certifications. Additionally, contractors must report unusual incidents including deaths, serious illness or injury, abuse allegations, fire, theft, property damage, patient criminal charges or incarceration, communicable disease outbreaks, inappropriate relationships between patients and staff, and chronic complaints from patients or families. The report also requires submission of facility maintenance problem narratives. All incident reports must be submitted via secured email alongside the monthly submission. This template does not address pricing, response dates, set-asides, or contract vehicles, as it functions solely as a reporting and compliance documentation mechanism for ongoing contract administration.
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Text version
Attachment J-9: 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
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
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 a 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 a Patient and contract staff
Chronic complaints from Patient’s families or Patients themselves
Other:
Monthly Physical Plan Issues (Provide narrative, describing all serious facility maintenance problems):
File details come from the government source that posted it. Updated .