Exhibit XIV Provider Census Report 2024.xlsm

XLSM spreadsheet 89 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071439
Contract number: CTR071439
Issued by: Arizona

About this file

Written by GovTribe AI · Sep 19, 2025

This document is an Exhibit XIV Provider Census Report for the Arizona Department of Child Safety (ADCS), specifically a congregate care census reporting template. The document is designed for tracking child placements in congregate care facilities, involving multiple providers, facilities, and placement sources including Arizona Department of Child Safety (ADCS), Arizona Juvenile Court (ADJC), and Tribal placements across various Arizona counties.

The report captures detailed information about child placements, including facility locations, licensed and contracted bed capacities, daily placement contacts, after-hours placement contacts, and comprehensive child placement data. Key tracking elements include child demographics, placement dates, exit dates, bed availability, facility specialties, contact information, and placement source details. The report requires daily submission by 5pm to OpenBeds@azdcs.gov, with providers required to update information about child placements, facility vacancies, and placement sources across different facility types and locations within Arizona's child welfare system.

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Agency Face Sheet

	Arizona Department of Child Safety
Congregate Face Sheet		V5

Provider
Provider Name	License Information
Quick Connect #	Contracted Population
Admin. Office Address	Contracted Age Range

Daily Placement (7 days a week 8am-5pm)
Name (Main Contact)	Name (Backup Contact)
Email Address (Main Contact)	Email Address (Backup Contact)
Phone # (Main Contact)	Phone Number (Backup Contact)

After Hour Placement (7 days a week 5pm-8am)
Name (Main Contact)	Name (Backup Contact)
After Hours Placement Phone #	After Hours Placement Phone # (Backup)

Facility Locations
Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Speciality	Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
Vacant Beds	Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address (If applicable)
Facility Phone Number	Facility Phone Number

DCS Census Report

	Due:Daily No later than 5pm.
Send to: OpenBeds@azdcs.gov		Arizona Department of Child Safety

Congregate Care Census Report

	This roster shall contain only ADCS Congregate Care, ADJC and Tribal Placements												Current Date:
	Length of Stay (Days)	Child's Age	Child's Full Name
(Last, First)	Placement Date
xx/xx/xxxx	Exit Date xx/xx/xxxx	Bed Hold End Date	Destination Detail
(drop down)	Child's Gender	DOB
xx/xx/xxxx	Person ID #	Case ID# or Assessment ID#	Facility Name	Cottage/Casita	Placement Source	School Name	County for Dually Adjudicated	Probation	Probation Officer Contact Information	Comments
		child age	child name	placement date	exit date		details	children	childdob		facility	source
	0	0					AWOL
	0	0
	0	0
	0	0
	0	0
	0	0
	0	0
	0	0
	0	0
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	0	0
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DCS Exit Dates

	Child's Age	Child's Full Name
(Last, First)	Exit Date xx/xx/xxxx	Bed Hold End Date	Destination Detail
(drop down)	Child's Gender	DOB
xx/xx/xxxx	Person ID #	Facility Name	Cottage/Casita
	child age	child name	exit date	details	children	childdob	facility

Instructions

This User Guide is intended to provide helpful tips for completing the Agency Face Sheet, Census Report, and Subcontractor tabs.

ADCS Congregate Care Census Reports are due daily by 5pm.

Congregate Care Agency Face Sheet

Provider - This section is to obtain the Contractors information that they are both Licensed and Contracted for

Enter Provider name as it appears on your ADCS OLR License

Enter Quick Connect ID # as it appears on your Congregate Care Quick Connect profile

Enter the Administrative Office Address that matches your ADCS OLR License and AZ W9 on file

Enter the License Information- enter your ADCS Contracted population

Enter the Population which is your ADCS Contracted Gender(s)

Enter your Age Range that your are ADCS Contracted for

Daily Placement- this section is to enter the contact information from the Contractor for ADCS Placement Administration 7 days a week 8am-5pm for placement of children

Enter the Name of the person who will be point of contact

Enter the Email Address for receiving placement referrals and communication

Enter the Phone Number for receiving calls from ADCS Placement Administration

Enter the Name of the Back up Person who may support the main person

Enter the Back up Email of who may support the main email

Enter the Back up Phone number for receiving calls from ADCS Placement Administration

Facility Locations- this section is for the Provider to enter the ADCS Non QRTP Congregate Care Facilities only where children may be placed

Enter the Facility name as it appears on your ADCS OLR Operating Certificate or License

Enter the Cottage /Casita Name that accepts ADCS Non QRTP placements, Tribal or ADJC children

Enter the Cohort and Speciality for this Facility and or Cottage/Casita

Enter the Number of Licensed Beds for this Facility and or Cottage/Casita

Enter the Number of Contracted Beds for this Facility and or Cottage/Casita

Enter the Number of Vacant Beds for this facility and or Cottage/Casita, this should not include any current Bed Holds

Enter the Facility Email address if there is one

Enter the Facility Phone Number this should be a direct line for this location

Congregate Care Census Report

Census Report- this Tab is to updated and submitted daily for an accurate count of current ADCS, ADJC and Tribal placements and vacant beds available to the Department. This does not include QRTP, ORR, Private or AOC placements.

Length of Stay in Days will autopopulate when the placement date is entered

Child's Age will autopopulate when the Child's Date of Birth (DOB) is entered

Child Full Name shall be entered Last Name, First Name upon placement

Placement Date shall be the date the child was physically placed in the facility and correlate with the date on the child's Notice to Provider

Exit Date shall be the date the child left the facility permanently, this does not include a bed hold

Bed Hold End Date shall be the date child returned or exited the facility. Bed may then reflect as vacant

Destination Details shall be where the child went after they exited the facility

Child's Gender shall be what the child is assigned at birth and correlate with the gender on the Notice to Provider

DOB shall be the child's date of birth and entered accurately

Guardian Person ID Number shall be entered and match the Notice to Provider information

Facility Name shall be where the child was placed and should correlate with the Placement Referral and Notice to Provider

Cottage/Casita shall be entered only if an ADCS assigned and applicable to the Contractor

Placement Source shall be entered as ADCS, Tribal or ADJC

School Name shall be the child school of orgin when placed and updated if an approved move with a BID is held.

County for Dually Adjucated shall be the county the youth is assigned

Probation shall be entered if the child is currently on Probation

Probation Officer Contact Information shall include Name and Phone Number

Comments shall be for any information that needs to be entered but is unable to be

Drop Down

Drop Down Menu
Destination Details	Child Sex	Meaningful Contact	CFT Participation	Normalcy Activities	Months
Aged Out	F	Yes	Yes	Yes	August 1st to 31st (due 2nd Thursday in Sept.)
AWOL	M	No	No	No	September 1st to 30th (due 2nd Thursday in Oct.)
Detention		No contact permitted	Other (does not apply) - see comments	Child exited agency	October 1st to 31st (due 2nd Thursday in Nov.)
Disruption	Placement Source	Child exited agency	Extracurricular Activites	Cohort Limitations	November 1st to 30th (due 2nd Thursday in Dec.)
Foster Home	DCS	Not placed these dates	Student Government	Other (does not apply) - see comments	December 1st to 31st (due 2nd Thursday in Jan.)
Group Home	ADJC	Other (does not apply) - see comments	Music/ Art/ Culture Club		January 1st to 31st (due 2nd Thursday in Feb.)
Higher Level Care	AOC		Volunteer Work		February 1st to 29th(due 2nd Thursday in March)
Hospital	ORR		Athletics / Sports		March 1st to 31st (due 2nd Thursday in April)
Independent Living	Tribal		Cohort Limitations		April 1st to 30th (due 2nd Thursday in May)
Kinship	Private		Internship		May 1st to 31st (due 2nd Thursday in June)
Reunification			After School Program		June 1st to 30th (due 2nd Thursday in July)
Other - see comments			Summer Camp		July 1st to 31st (due 2nd Thursday in August)
			Child is under 7yrs old
			Other activity - see comments
School status		Is staff information updated in quick connect	Other (does not apply) - see comments
Changed Schools (with DCS specialist approval)		Yes
Changed Schools ( W/O DCS approval)		No - See comments
Remained in School of Origin
Not School Aged
Other - see comments		County for Dually Adjudicated	Dually Adjudicated		Destination Details SUB CONTRACTED	Placement Source
		Apache	Yes		Aged Out	DCS
		Cochise	No		AWOL	ADJC
QRTP		Coconino			Detention	Tribal
Yes		Gila			Disruption
		Graham			Foster Home
		Greenlee			Group Home
		La Paz			Higher Level Care
		Maricopa			Hospital
		Mohave			Independent Living
		Navajo			Kinship
		Pima			Other - see comments
		Pinal			QRTP
		Santa Cruz			Reunification
		Yavapai
		Yuma

Totals

CFT
Yes	ERROR:#REF!
No	ERROR:#REF!
Blank	ERROR:#REF!	ONLY for monthly reports
percentage	ERROR:#REF!

Extracurricular Activites
Student Government	ERROR:#REF!
Music/ Art/ Culture Club	ERROR:#REF!
Volunteer Work	ERROR:#REF!
Athletics / Sports	ERROR:#REF!
Cohort Limitations	ERROR:#REF!
Internship	ERROR:#REF!
After School Program	ERROR:#REF!
Summer Camp	ERROR:#REF!
Child is under 7yrs old	ERROR:#REF!
Other actvity - see comments	ERROR:#REF!
Other (does not apply) - see comments	ERROR:#REF!
Blank	ERROR:#REF!
Percentage of participation	ERROR:#REF!
Meaninful
Yes	ERROR:#REF!
No	ERROR:#REF!
No contact permitted	ERROR:#REF!
Child exited agency	ERROR:#REF!
Not placed these dates	ERROR:#REF!
Other (does not apply) - see comments	ERROR:#REF!
Blank	ERROR:#REF!
Totals	ERROR:#REF!
Normalcy
Yes	ERROR:#REF!
No	ERROR:#REF!
Child exited agency	ERROR:#REF!
Cohort Limitations	ERROR:#REF!
Blank	ERROR:#REF!
Other (does not apply) - see comments	ERROR:#REF!
Total	ERROR:#REF!
School of orgin
Blanks	ERROR:#REF!
changed schools (DCS Approval)	ERROR:#REF!
changed schools (W/O Approval)	ERROR:#REF!
Reamined in school of orgin	ERROR:#REF!
Not school aged	ERROR:#REF!
total children in placement	ERROR:#REF!
% of children remaining in school of origin	ERROR:#REF!

File details come from the government source that posted it. Updated Sep 19, 2025.