Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form from the Arizona Department of Child Safety. It is designed for contractors to request the holding of a bed for a child in care under specific circumstances such as AWOL, detention, extended visit, hospitalization, or other reasons. The form requires details about the child, including their name, PID (Personal Identification), and the contractor's information, with provisions for bed holds up to 7 days by the Statewide Placement Program Manager and up to 14 days with the Statewide Placement Program Administrator's signature.

The form provides checkboxes for various reasons for bed hold requests and requires documentation of specific conditions like confirming calls to the Hotline and Police Department in AWOL situations. The document includes fields for the actual start and end dates of the bed hold, the number of days requested, and signature lines for the contractor and Statewide Placement Program Manager/Administrator. Completed forms can be submitted via email to BedHold@azdcs.gov or through a submit button, indicating a digital submission process for tracking and approving bed hold requests for children in the care of the Arizona Department of Child Safety.