Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form issued by the Arizona Department of Child Safety. The form is designed for contractors to request a bed hold for a child in congregate care under specific circumstances such as AWOL, detention, extended visit, or hospitalization. The form requires details about the child, including name, PID (Personal Identification), and the requested duration of the bed hold.

The document specifies that the Statewide Placement Program Manager can approve up to 7 days of bed hold, while the Statewide Placement Program Administrator can authorize up to 14 days. The form must be completed by the contractor, who provides the reason for the bed hold and confirms any necessary actions like calling the hotline or police department. Completed forms can be submitted via email to BedHold@azdcs.gov or through a submit button on the form. The document requires signatures from the contractor and the Statewide Placement Program Manager/Administrator to validate the bed hold request.