Exhibit XIX ADJC Census Report.doc

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Attached to
Master Agreement AZ|CTR071466
Contract number
CTR071466
Issued by
Arizona

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This document is an Arizona Department of Juvenile Corrections (ADJC) Census Report template for out-of-home residential contractors providing youth residential services. The document is specifically designed for contractors to report bed space availability for Arizona residential programs, with instructions to email the completed report to the Community Program Service Office (CPSO) on the 1st and 15th of each month.

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 by city, and indication of upcoming discharges. Contractors are instructed to submit the report by 10:00 AM and can contact CPSO at 602-527-5267 for training or assistance with completing the report. The document was last revised on 6/20/22 and serves as a standardized tracking mechanism for residential program capacity and availability.

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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 .