Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071407
- Contract number
- CTR071407
- Issued by
- Arizona
About this file
This document is an Arizona Department of Juvenile Corrections (ADJC) monthly attendance reporting template designed for out-of-home contractors providing juvenile care services. The form is specifically intended for contractors to document and report monthly attendance and service details for juveniles in their care, with reporting required to be submitted to the Community Program Service Office (CPSO) by the 3rd business day of each month following service provision.
The reporting template requires contractors to comprehensively track individual juvenile placement information, including ADJC identification number, level of care/program type, placement date, days and reasons for absences, and discharge details. The document supports accountability and tracking for juveniles placed through various funding sources, including Arizona Department of Child Services (DCS), Regional Behavioral Health Authorities (RBHA), interstate placements, private pay, and other agencies. Contractors must complete the form with detailed individual juvenile information and submit it electronically to the specified ADJC email address, with contact support available through the CPSO at 602-527-5267.
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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 .