Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071425
- Contract number
- CTR071425
- 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 services to juvenile offenders. The form is to be completed monthly by contractors and submitted to the ADJC Community Program Service Office (CPSO) via email by the 3rd business day of the following month. The report requires detailed tracking of juveniles in care, including those placed or funded by other agencies such as the Department of Child Services (DCS), Regional Behavioral Health Authorities (RBHA), interstate placements, private pay, or other sources.
The report template captures critical information about each juvenile, including ADJC identification number, level of care/program type (such as BHIF, BHRF, Group Home, Shelter Care), placement date, days and reasons for absences, discharge date, and discharge reason. Contractors are instructed to list each juvenile individually and provide comprehensive accountability information. The document includes contact information for the CPSO for training or assistance, with a contact number of 602-527-5267 and an email address of communityprogramservice@azdjc.gov. The form was last revised on 6/20/22 and is designed to ensure precise tracking and reporting of juvenile placements and movements within the contract system.
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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 .