Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071423
- Contract number
- CTR071423
- Issued by
- Arizona
About this file
The document is an Arizona Department of Juvenile Corrections (ADJC) Monthly Attendance Report template for out-of-home contractors. It is designed to track and report juvenile placements and attendance for various care facilities, including behavioral health, group homes, shelter care, and other program types. The report must be submitted electronically to the ADJC Community Program Service Office (CPSO) by the 3rd business day of the following month.
The reporting form requires contractors to document detailed information for each juvenile in their care, including ADJC identification number, level of care/program type, placement date, days absent, absence reasons, discharge date, and discharge reasons. The form applies to juveniles placed through multiple funding sources, such as the Department of Child Services (DCS), Regional Behavioral Health Authorities (RBHA), interstate agreements, private pay, and other agencies. Contractors can contact CPSO at 602-527-5267 for training or assistance in completing the report.
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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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