Free Total Expenses All Sources, by Target Group and Standard Program Cluster - Wisconsin


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State: Wisconsin
Category: Health Care
Author: DHS
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Page Size: Letter (8 1/2" x 11")
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http://dhs.wisconsin.gov/forms1/f2/f20942a.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20942A (05/2009)

TOTAL EXPENSES ALL SOURCES BY TARGET GROUP AND STANDARD PROGRAM CLUSTER
NAME ­ Agency Contact Telephone ­ Agency Contact

STATE OF WISCONSIN Completion of this form meets the requirements of the State / County contract specified under s. 46.031 (2g), Wis. Stats.

REPORT YEAR __________

TARGET GROUPS
Developmental Disability (1) Alcohol / Other Drug Abuse (3) Physical And Sensory Disability (4) Delinquent and Status Offender (5) Abused And Neglected Children (6) Children And Families (7) Adults And Elderly (8) TOTAL Expenses Columns (1) Thru (8)

STANDARD PROGRAM CLUSTER

Mental Health (2)

100 Child Day Care - Crisis Respite 104 Supportive Home Care 107 Specialized Transportation and Escort 200 Access, Outreach And Prevention 300 Community Living / Support Services 400 Investigations and Assessments 500 Community Support Programs 600 Work-Related and Day Services 615 Supported Employment 700 Community Residential Services 800 Community Treatment Services 900 Inpatient and Institutional Care Including IMD 950 Juvenile Corrections

TOTAL
SUBTOTALS Adult ­ Age: 18 years and over Child ­ Age: Under 18 years