Exhibit XIX ADJC Census Report.doc

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Attached to
Master Agreement AZ|CTR071444
Contract number
CTR071444
Issued by
Arizona

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The document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template for out-of-home residential contractors. It is a standardized reporting form requiring contractors to provide bed space availability for Arizona residential juvenile programs. The report is to be submitted electronically to the ADJC Community Program Service Office (CPSO) via email on the 1st and 15th of each month by 10:00 AM.

The report template requires contractors to detail specific program information including: contractor name, reporting week, contact information, level of care (such as BHIF, BHRF, Group Home), specialty, gender, age range, number of open beds, location by city, and indication of upcoming discharges. Contractors can receive training or assistance by contacting the CPSO at 602-527-5267. The document was revised on 6/20/22 and appears to be a critical tracking mechanism for juvenile residential program capacity and availability across Arizona.

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EXHIBIT XIX

ADJC Census Report

Out-of-Home residential Contractors, please provide your bed space availability for AZ residential programs. Email the completed report on 1st and 15th of the month by 10:00 AM to the ADJC Community Program Service Office (CPSO) at communityprogramservice@azdjc.gov For training or assistance regarding this report, please contact the CPSO at 602-527-5267.

Contractor name:
Census for the week of

Contact person phone and email:

Level of Care

(BHIF, BHRF, Group Home or Other)

Specialty
Gender
Age

Range # of open beds Location (City) Upcoming

Discharges

(Y or No)

REV 6/20/22

File details come from the government source that posted it. Updated .