Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071439
- Contract number
- CTR071439
- Issued by
- Arizona
About this file
This document is an Arizona Department of Juvenile Corrections (ADJC) Monthly Attendance Report template designed for out-of-home contractors providing juvenile care services. The report is to be completed monthly and submitted electronically to the Community Program Service Office (CPSO) by the 3rd business day of the following month, with contact support available at 602-527-5267.
The report template requires contractors to document detailed information about ADJC juveniles in their care, including individual tracking across multiple care settings such as BHIF, BHRF, Group Home, Shelter Care, or other programs. Contractors must record each juvenile's identification number, level of care, placement date, days absent, absence reasons, discharge date, and discharge reasons. The document supports accountability and monitoring of juvenile placement services, with provisions for tracking juveniles placed or funded by multiple agencies including DCS, RBHA, Interstate, Private Pay, or other entities.
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Text version
EXHIBIT XVIII
ADJC Monthly Attendance Report
Out-of-Home Contractors, please complete this report on a monthly basis to confirm accuracy in the accountability of ADJC juveniles in your care. This report shall be emailed to the ADJC Community Program Service Office (CPSO) at communityprogramservice@azdjc.gov by no later than the 3rd business day of the following month. For training or assistance regarding this report, please contact the CPSO at 602-527-5267.
| Contractor Name: |
| Month/Year services provided: |
Contract number _ ___________ Please list all ADJC juveniles in your care including those placed and/or funded by another Agency i. e. DCS, RBHA, Interstate, Private Pay or Other (Type the first and last name;
Include one juvenile per line)
ADJC
K #
Level of Care/Program
BHIF, BHRF, Group Home, Shelter Care or Other
Date placed in the program
Days absent during the month
| Reason for the absence |
| Discharge Date |
| Reason for the discharge |
1.
2.
3.
4.
5.
6.
7.
| Report completed by |
| Date |
| Phone |
| REV 6/20/22 |
| page 1 |
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