Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071434
- Contract number
- CTR071434
- Issued by
- Arizona
About this file
The document is an Arizona Department of Juvenile Corrections (ADJC) Monthly Attendance Report template designed for out-of-home contractors providing juvenile care services. The form is specifically used by contractors to report monthly attendance and status of ADJC juveniles placed in various care settings, such as group homes, shelters, and other residential programs. The report must be submitted electronically to the ADJC Community Program Service Office (CPSO) by the 3rd business day of the following month.
The report requires detailed tracking of individual juveniles, including their ADJC identification number, level of care/program type, placement date, days and reasons for absences, discharge date, and discharge reason. The form accommodates multiple juveniles and is to be completed by the contractor's representative, who must provide contact information. While no specific pricing or contract terms are detailed in this document, it serves as a critical accountability and tracking mechanism for juvenile placement and care services across different funding sources, including ADJC, Department of Child Services (DCS), Regional Behavioral Health Authorities (RBHA), interstate placements, and private pay arrangements.
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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 .