Exhibit XIX ADJC Census Report.doc

105 KB Posted

Attached to
Master Agreement AZ|CTR071405
Contract number
CTR071405
Issued by
Arizona

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This document is an ADJC (Arizona Department of Juvenile Corrections) Census Report template for out-of-home residential contractors providing juvenile residential programs. The report is designed for contractors to communicate bed space availability to the Arizona state agency, specifically the Community Program Service Office (CPSO), located in Phoenix.

The census report requires contractors to email bed availability information twice monthly (on the 1st and 15th) by 10:00 AM, detailing specific program attributes including level of care (BHIF, BHRF, Group Home), specialty, gender, age range, number of open beds, location, and upcoming discharge status. Contractors can obtain training or assistance by contacting the CPSO at 602-527-5267, with the report submission email being communityprogramservice@azdjc.gov. The document was last revised on 6/20/22 and provides a standardized tracking mechanism for juvenile residential program capacity 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 .