Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071412
- Contract number
- CTR071412
- 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 services. The form is specific to the state of Arizona and is intended to be completed monthly by contractors caring for ADJC juveniles, with submission required by the 3rd business day of the following month to the Community Program Service Office (CPSO).
The report template requires contractors to document detailed information about juveniles in their care, including ADJC identification numbers, level of care/program type, placement dates, days and reasons for absences, discharge dates, and discharge reasons. The form covers various placement types such as BHIF, BHRF, Group Home, Shelter Care, and other program categories. Contractors must include 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. The document provides contact information for technical assistance and reporting, with a revision date of 6/20/22.
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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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