Exhibit XIX ADJC Census Report.doc

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Master Agreement AZ|CTR071407
Contract number
CTR071407
Issued by
Arizona

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The document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template designed for out-of-home residential contractors. The report is specifically targeted at service providers within Arizona's juvenile justice system, requiring them to submit bed space availability for residential programs to the Community Program Service Office (CPSO).

The report template mandates contractors to email a standardized census document on the 1st and 15th of each month by 10:00 AM, detailing critical information including contractor name, level of care (such as BHIF, BHRF, Group Home), specialty, gender, age range, number of open beds, location, and upcoming discharge status. Contact information and a phone number (602-527-5267) for training or assistance is provided, with the report being revised as of 6/20/22. The document serves as a tracking mechanism for residential program capacity and availability within Arizona's juvenile corrections system.

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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 .