Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071426
- Contract number
- CTR071426
- 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 a standardized reporting form designed for facilities and service providers caring for juveniles, with specific submission requirements to the Community Program Service Office (CPSO). The report must be completed monthly and emailed by the 3rd business day of the following month to communityprogramservice@azdjc.gov, with support available at 602-527-5267.
The report template requires detailed tracking of individual juveniles, including their ADJC identification number, level of care/program type (such as BHIF, BHRF, Group Home, Shelter Care), placement date, days absent, absence reasons, discharge date, and discharge reasons. The form is intended to provide comprehensive accountability for juveniles placed in various care settings, potentially including placements funded by multiple agencies like DCS, RBHA, Interstate, Private Pay, or other sources. The document was revised on 6/20/22 and provides a structured mechanism for monitoring juvenile placement and care across different service providers.
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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 .