ࡱ> q` rebjbjqPqP jv::fR$"""PR".#4^Rn#0*(**** /2hQQQQQQQ$sShULQ8**88Q**ARIII8n**QI8QIIVvP@:Q*b# op"e>8P QWR0RPx'VCV'V:Q'V:QT4:@5I 66#444QQH444R8888^^^"^^^"&4Z, ANNEX A LEVEL OF SERVICE SUMMARY SHEET AGENCY NAME:  FORMTEXT       CONTRACT NUMBER:  FORMTEXT       BUDGET MODIFICATION NO: Service Commitments from the Period: (0 = Original)  FORMTEXT        FORMTEXT       to  FORMTEXT       PROGRAM ELEMENT:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       BUDGET MATRIX CODE:  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       1. Total Clients to be Served  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       2. Number of New  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Enrollees and Transfers Of the New Enrollees and  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Transfers (item 2 above), How many are: a. Clients with Prior NJ State  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       or County Hospitalization b, Clients Enrolled within 30  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       days of Discharge from State Psychiatric Hospitals c. Clients Enrolled within 30  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       days of Discharge from County Psychiatric Hospitals d, Clients Enrolled within 30  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       days of Discharge from a ShortTerm Care Facility e, Clients Enrolled within 30  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       days from "Other Hospitals" f, Persons in the Community  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       atrisk of Psychiatric Hospitalization ANNEX A LEVEL OF SERVICE SUMMARY SHEET AGENCY NAME:  REF Text99   CONTRACT NUMBER:  REF Text100   BUDGET MODIFICATION NO:  REF Text101   Service Commitments from the Period: (0 = Original)  REF Text102   to  REF Text103   PROGRAM ELEMENT:  REF Text104    REF Text2    REF Text3    REF Text4   BUDGET MATRIX CODE:  REF Text105    REF Text9    REF Text10    REF Text11   g. African Americans  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       h. Hispanics  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       i. Children (17 &  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Younger) j. Elderly (65 & Older)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       k. At Poverty Level  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       I. Boarding Home  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Residents m. 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Homeless  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       o. Other Target Group  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       (Specify) p. Not Target Group  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Eligible LEVEL OF SERVICE DEFINITIONS 1. TOTAL CLIENTS TO BE SERVED: refers to the number of active cases at the beginning of the contract reporting period plus the projected number of new enrollees and transfers to the program element during the contract period. 2. NEW ENROLLEES: refers to the number of new cases to be opened and re-opened (as a USTF case) during the contract reporting period. TRANSFERS: refers to clients who are in-house during the contract period, but move within agency program elements. 2b. STATE HOSPITALS: refers to the five state psychiatric hospitals located in New Jersey, only: Greystone Park, Trenton, Ancora, Hagedorn and Forensic. 2c. COUNTY HOSPITALS: refers to the six county hospitals in New Jersey: Bergen, Burlington, Camden, Essex, Hudson and Union. 2d. SHORT-TERM CARE FACILITY (STCF): refers to inpatient community-based mental health treatment facilities, designated by DMHS which provide acute care treatment and assessment of services to mentally ill individuals whose mental illness causes them to be dangerous to self, others or property. 2e.  OTHER HOSPITAL: refers to any psychiatric hospital or in-voluntary psychiatric unit within a hospital in NJ that is not a State or County hospital; or a designated STCF; or any public or private psychiatric hospital located outside New Jersey. 2f. PERSONS IN THE COMMUNITY AT-RISK OF PSYCHIATRIC HOSPITALIZATION: refers to individuals who are currently in crisis and/or are marginally functioning (GLOF or 5 or under) and without intervention would likely be hospitalized. 2k. AT POVERTY LEVEL: refers to individuals at the following income levels based on the US Bureau of Census table: Poverty Thresholds in 2007, by Size of Family and Number of Related Children Under 18 years. (Source: http://www.census.gov/hhes/www/poverty/threshld/thresh07.html) Family Size Income 1 $10,787 2 $14.291 3 $16,705 4 $21,100 5 $24,366 6 $27,187 7 $31,031 8 $35,255 9 or more $43,004     2/08 Page  PAGE 3 of  NUMPAGES 3 filename-LOS Summary RRRRRRRRRRRRRRRS0S2SFSHSJSTSVSZS\SpSrStS~SSSSﱕxdP&j%h;` h':CJU\^J&jz%h;` h':CJU\^Jh;` hd4CJ\^J jh;` hd4CJU\^Jh':CJ^J&j%h;` h':CJU\^Jh':5CJ\^J%jh;` CJU\^JmHnHu&j$h;` h':CJU\^Jh;` h':CJ\^J jh;` h':CJU\^JSSSSSSSSSSSSSSSTT0T2T4T>T@TDTFTZT\T^ThTjTnTpTλΰλΰwcOλΰ&j'h;` h':CJU\^J&jT'h;` h':CJU\^Jh;` hd4CJ\^J jh;` hd4CJU\^Jh':CJ^J&j&h;` h':CJU\^Jh':5CJ\^J%jh;` CJU\^JmHnHu jh;` h':CJU\^J&jh&h;` h':CJU\^Jh;` h':CJ\^JpTTTTTTTTTTTTTTTTTUUUNUPUUλΰλΰsj]M?]h?ho95CJ^JaJhcho956CJ^JaJh?ho9CJ^JaJho95>*^Jhiho96CJ^JaJho96CJ^JaJho9CJ^Jh':CJ^J&j(h;` h':CJU\^Jh':5CJ\^J%jh;` CJU\^JmHnHu jh;` h':CJU\^J&jB(h;` h':CJU\^Jh;` h':CJ\^JUUVVVVV^W`W~WWWWWXnXrXXXXZ0Z2Z [H[L[t[v[[[\\\\\\\\b]]]X____>`@`&aFaHaaaabbbb4bٴ霑h[5CJ^JaJho9ho95CJ^JaJh[CJ^JaJh[56CJ^JaJho9CJ^JaJh?ho95CJ^JaJhcho956CJ^JaJh?ho9CJ^JaJh XmCJ^JaJ9UVVVWWXXZZ[[X]Z]N_P_aabPcRccc^gdGo 0^`0gdGo 0^`0gd[^gd Xmgdo9 0^`0gd Xm4b8bbbbbNcPcTcVclcnctcvcccccccccc ddd.d0d:d>dRd\dtd~ddddddddddddddde潭歜ۉ}hGoCJ^JhjhUh Xm5CJ^JaJ!hcho956>*CJ^JaJhcho956CJ^JaJ ho95^JhGoCJ^JaJho9ho9CJ^JaJhGo5CJ^JaJh?ho95CJ^JaJho95CJ^JaJ0ccccd2dTdvddddddddddddjeleneperegdGogdo9eeeeeee e4e6e8e:ehejenepereɾhGo5CJ^JaJhhGohGoCJ^Jh^a<0JmHnHuh0JmHnHu hGo0JjhGo0JU. 00/ =!X"#`${% 8 00P:p Xm/ =!"#$% vD@Text99xD@Text100xD@Text101xD@Text102xD@Text103xD@Text104tD@Text2tD@Text3tD@Text4xD@Text105tD@Text9vD@Text10vD@Text11xDText106vDText13vDText14vDText15xDText107vDText17vDText18vDText19vDText20vDText21vDText22vDText23xDText108vDText25vDText26vDText27xDText109vDText29vDText30vDText31xDText110vDText33vDText34vDText35xDText111vDText37vDText38vDText39xDText112vDText41vDText42vDText43xDText113vDText45vDText46vDText47xDText116vDText60vDText61vDText62xDText117vDText64vDText65vDText66xDText118vDText68vDText69vDText70xDText119vDText72vDText73vDText74xDText120vDText76vDText77vDText78xDText121vDText80vDText81vDText82xDText122vDText84vDText85vDText86xDText123vDText88vDText89vDText90xDText124vDText92vDText93vDText94xDText125vDText96vDText97vDText98T@T Normal1$7$8$H$ CJOJQJ_HaJmH sH tH B@B Heading 1$@&5CJ\^JN@N Heading 2$$@&a$56CJ\]^JDA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List 22 OmniPage #122 OmniPage #222 OmniPage #322 OmniPage #4424 Header  !4 @B4 Footer  !.)@Q. 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