Exhibit XIX ADJC Census Report.doc
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- Attached to
- Master Agreement AZ|CTR071450
- Contract number
- CTR071450
- Issued by
- Arizona
About this file
This document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template designed for out-of-home residential contractors providing residential programs. The document is specific to Arizona state juvenile corrections services and requires contractors to report bed space availability to the Community Program Service Office (CPSO) via email on the 1st and 15th of each month.
The census report template 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 by city, and indication of upcoming discharges. Contractors are instructed to email the completed report by 10:00 AM to communityprogramservice@azdjc.gov, with technical support available by calling 602-527-5267. The document was last revised on 6/20/22 and appears to be a standardized tracking mechanism for monitoring residential program capacity and availability for juvenile corrections placements.
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Text version
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 .