Exhibit XII Bed Hold.pdf
PDF 50 KB Posted
- Attached to
- Master Agreement AZ|CTR071410
- Contract number
- CTR071410
- Issued by
- Arizona
About this file
The document is a Congregate Care Bed Hold Authorization form issued by the Arizona Department of Child Safety (DCS). It is a standardized form designed for contractors to request the holding of a child's bed in a congregate care facility during specific circumstances such as AWOL (absent without leave), detention, extended visits, hospitalization, or other reasons.
The form allows for bed holds up to 7 days with approval from the Statewide Placement Program Manager, and up to 14 days with additional approval from the Statewide Placement Program Administrator. The document requires specific details including the child's name, personal identification number (PID), contractor information, facility name, actual start and end dates of the bed hold, and the reason for the request. Completed forms can be submitted electronically to BedHold@azdcs.gov or via a submit button on the form.
View the file
Other files
Show all 46
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Exhibit XII (05/24)
CONGREGATE CARE
BED HOLD AUTHORIZATION
ARIZONA DEPARTMENT OF CHILD SAFETY
Facility Name:
Actual end date of the bed hold:
Contractor
Actual start date of the bed hold:
Child’s Name: Date of Request:Child’s PID:
Number of days requested:
Client Information
AWOL: Confirm calls to Hotline and PD were made
Hospitalization
I am requesting that a bed hold be established for the above child under the above conditions.
NOTE: Completed forms can be submiteed to BedHold@azdcs.gov or via the submit button
Note: Statewide Placement Program Manager can approve up to 7 days of bed hold. Beds can be held for up to 14 days with the Statewide Placement Program Administrator’s signature.
Reason for request:
Extended Visit (waiting for CPC)
Detention
Other [please explain]:
Contractor Signature
Statewide Placement PM/PA
Date
Date
Signatures
| Text Field 13: |
| Text Field 5: |
| Text Field 8: |
| Text Field 4: |
| Text Field 7: |
| Text Field 1: |
| Text Field 10: |
| Text Field 12: |
| Text Field 11: |
| Text Field 14: |
| Text Field 3: |
| Text Field 2: |
| Text Field 6: |
| Radio Button 9: Off |
| Text Field 15: |
| Text Field 17: |
| Text Field 16: |
| Text Field 18: |
| Button 19: |
File details come from the government source that posted it. Updated .