Exhibit XVIII ADJC Monthly Attendance Report.doc
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- Attached to
- Master Agreement AZ|CTR071666
- Contract number
- CTR071666
- Issued by
- Arizona
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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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