Exhibit XIX ADJC Census Report.doc

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Master Agreement AZ|CTR071441
Contract number
CTR071441
Issued by
Arizona

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This document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template designed for out-of-home residential contractors providing juvenile residential services in Arizona. The document is specifically intended for contractors to report bed space availability to the ADJC Community Program Service Office (CPSO), with reporting requirements on the 1st and 15th of each month by 10:00 AM via email.

The census report requires contractors to provide detailed information including contractor name, contact details, level of care (such as BHIF, BHRF, Group Home), specialty, gender, age range, number of open beds, location (city), and indication of upcoming discharges. The report serves as a tracking mechanism for residential program capacity and availability, enabling the ADJC to monitor and manage juvenile residential placements across different care levels and geographic locations within Arizona. Contractors can obtain training or assistance by contacting the CPSO at 602-527-5267.

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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 .