Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071440
- Contract number
- CTR071440
- 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. The document is specifically used to track and report on juveniles placed in various care settings such as BHIF, BHRF, Group Homes, Shelter Care, or other program types.
The report requires contractors to document detailed information about each juvenile in their care, including ADJC identification number, level of care, placement date, days absent, reason for absence, discharge date, and discharge reason. The form accommodates tracking of juveniles placed through multiple funding sources, including ADJC, Department of Child Services (DCS), Regional Behavioral Health Authorities (RBHA), Interstate placements, Private Pay, and other agencies. Contractors must complete the report with their contact information and can obtain assistance or training by contacting the CPSO at 602-527-5267.
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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 |
File details come from the government source that posted it. Updated .