Exhibit XVIII ADJC Monthly Attendance Report.doc
DOC document 104 KB Posted
- Attached to
- Master Agreement AZ|CTR071415
- Contract number
- CTR071415
- Issued by
- Arizona
About this file
The document is an Arizona Department of Juvenile Corrections (ADJC) Monthly Attendance Report template, designed for out-of-home contractors providing juvenile services. The report is to be completed monthly and submitted electronically to the Community Program Service Office (CPSO) by the 3rd business day of the following month, with contact support available at 602-527-5267.
The report requires contractors to document detailed information about ADJC juveniles in their care, including those placed or funded by other agencies such as DCS, RBHA, Interstate, Private Pay, or other sources. Contractors must list each juvenile's name, 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 is designed to ensure accountability and tracking of juveniles across different care settings and funding sources.
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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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