Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071413
- Contract number
- CTR071413
- 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 document is specifically targeted at contractors working with ADJC and requires monthly reporting to the Community Program Service Office (CPSO) via email by the 3rd business day of the following month.
The report template requires contractors to comprehensively document ADJC juveniles in their care, including details such as the juvenile's ADJC identification number, level of care/program type (BHIF, BHRF, Group Home, Shelter Care), placement date, days and reasons for absences, discharge date, and discharge reason. The form supports tracking and accountability for juveniles placed through various agencies including DCS, RBHA, Interstate, Private Pay, or other sources. Contact information is provided for training or assistance, with the CPSO available at 602-527-5267 and an email address of communityprogramservice@azdjc.gov.
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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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