Quarterly Contract Monitoring Forms (QCMR) and Annex A

Please e-mail completed QCMR Forms to: dmhs.qcmr@doh.nj.gov

Budget
Code

Program

Download
13 Designated Screening Center Adobe  Word
14 Early Intervention Support Services (EISS) Adobe  Word
15 Emergency Services Adobe  Word
18 Outpatient Adobe  Word
18 Bilingual, Bicultural Community & Outreach Adobe  Word
19 Intensive Outpatient Treatment and
Support Services (IOTSS)
Adobe  Word
21 & 23 Partial Care Adobe  Word
24 Residential Adobe  Word
27 Community Support Services Adobe  Word
28 Community Advocates/POST Adobe  Word
28 Legal Services Adobe  Word
29 & 34 Career Services (Supported Employment) Adobe  Word
31 PACT Adobe  Word
32 ICMS (Integrated Case Management Services) Adobe  Word
33 PATH Adobe  Word
35 Acute Care Family Support Programs Adobe  Word
35 IFSS (Intensive Family Support Services) Adobe  Word
36 Self-Help Centers Adobe  Word
38 Justice Involved Services Adobe  Word

Contracted program Commitments for DMHAS contracts should be prepared, stored and submitted utilizing the various Microsoft Word Templates listed below for those programs included in your DMHAS Contract:

  1. Choose the appropriate Annex A forms;
  2. Using the tab or arrow keys to cycle through the entry boxes, enter descriptive data and contract commitment figures in the pre-set data entry boxes;
  3. Save the forms with your own unique filename; and,
  4. Submit the proposed Annex A commitments to both your Regional Program Analyst and Contract Administrator.

NOTE:   Use the tab key or arrow keys to enter data and move between data boxes (do not use the "enter" key).

Should you have any questions or difficulty with this format, please call your Contract Administrator at (609) 777-0628.

Annex A Forms
Budget
Code

Program

Download
13 Designated Screening Center Services Adobe  Word
15 Emergency Services Adobe  Word
18 Outpatient Services Adobe  Word
18 Bilingual, Bicultural Community and
Outreach Services
Adobe  Word
19 Intensive Outpatient Treatment and
Support Services
Adobe  Word
21 & 23 Partial Care/Partial Hospitalization Adobe  Word
24 Residential Services Adobe  Word
27 Community Support Services Adobe  Word
28 Community Advocate/POST Adobe  Word
28 Legal Services Adobe  Word
29 & 34 Career Services Adobe  Word
31 PACT - Programs in Assertive Community
Treatment
Adobe  Word
32 ICMS - Integrated Case Management
Services
Adobe  Word
33 PATH - services for the homeless

(Level of Service Summary Sheet)
Adobe  Word

Adobe  Word
35 Acute Care Family Support Programs Adobe  Word
35 IFSS (Intensive Family Support Services) Adobe  Word
36 Self-Help Centers Adobe  Word
38 Justice Involved Services Adobe  Word


ANNEX A COVERPAGE / INSTRUCTIONS
PROGRAM & UNIT OF SERVICE DEFINITIONS
INFORMATION SHEET (required for each contracted Program)
PROGRAM COMMITMENTS SUMMARY (lists key Program figures)
CLIENTS CONTRACTED LEVEL OF SERVICE PROFILE

Last Reviewed: 11/3/2017