Exhibit XIX ADJC Census Report.doc

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Attached to
Master Agreement AZ|CTR071416
Contract number
CTR071416
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 programs in Arizona. The report is intended to be submitted by contracted service providers to the ADJC Community Program Service Office (CPSO) via email on the 1st and 15th of each month by 10:00 AM.

The census report requires contractors to provide detailed bed space availability information, including contractor name, contact details, level of care (such as BHIF, BHRF, Group Home), specialty, gender, age range, number of open beds, location, and indication of upcoming discharges. Contractors can obtain training or assistance by contacting the CPSO at 602-527-5267. The document appears to be a standardized tracking mechanism for monitoring residential placement capacity and availability for juvenile justice programs 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 .