Exhibit XIX ADJC Census Report.doc
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- Attached to
- Master Agreement AZ|CTR071410
- Contract number
- CTR071410
- Issued by
- Arizona
About this file
The document is an Exhibit XIX ADJC (Arizona Department of Juvenile Corrections) Census Report template for out-of-home residential contractors. The report is designed for contractors providing residential programs in Arizona, with instructions to submit bed space availability to the Community Program Service Office (CPSO) via email on the 1st and 15th of each month.
The census report requires contractors to provide detailed information including their level of care (such as BHIF, BHRF, Group Home, or Other), specialty, gender, age range, number of open beds, location (city), and upcoming discharges. Contractors are instructed to email the completed report by 10:00 AM to communityprogramservice@azdjc.gov, with technical support available by contacting the CPSO at 602-527-5267. The document was revised on 6/20/22 and serves as a tracking mechanism for residential program bed availability for juvenile corrections services in Arizona.
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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 .