Schedule Cqr-1 - Consolidated Quarterly Report - Office Of Mental Health Of New York State

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OASAS
SCHEDULE CQR-1
NE
W YORK STATE
CONSOLIDATED
FISCAL REPORTING SYSTEM
OMRDD
AGENCY QUARTERLY
Consolidated Quarterl
y Report
FISCAL SUMMARY
Fiscal Perio
d: 07/01/09 - 06/30/10
QUARTER REPORTED (Please Check):
_____1st
_____2nd
_____3rd
_____Mid-Year
_____Final
REVISION #_____
Page
AGENCY CODE: ________________________________
LGU:____________________________________
AGENCY NAME:__________________________________________________
PREPARED BY:__________________________________________________
COUNT NAM AND CODE: _____________________ (
Y
E
)
LGU APPROVAL BY:____________________________________
TELEPHONE:__________________________________________________
USE WHOLE DOLLARS ONLY
4
5
6
7
COLUMN NUMBER
1
2
3
PROGRAM TY
PE
PROGRAM TYPE
PROGRAM TYPE
PROGRAM TYPE
SERVICE PROVIDER
SERVICE PROVIDER
(
)
(
)
(
)
(
)
Line
ITEM DESCRIPTION
CODE
INDEX
CODE
INDEX
CODE
INDEX
CODE
INDEX
STATE AGENCY
YEAR-TO-DATE
TOTAL
No.
APPROVED BUDGET
TOTAL
FOR THIS QUARTER
ACCOUNTING METHOD
EXPENSES
Personal Services
1
2
Vacation Leave Accruals
3
Fringe Benefits
4
Other Than Personal Services
Equipment-Provider Paid
5
Property-Provider Paid
6
7
Agency Administration
8
Adjustments/Non-Allowable Costs
9
Total Expenses
(Lines 1-7 minus 8)
REVENUES
10
Please Check if Participant Specific Revenue Methodology is Used (OMRDD Only)
11
Medicaid Revenue
12
Non-Medicaid Revenue
Total Revenues
13
(Lines 11-12)
14
NET OPERATING COSTS
(Line 9 minus 13)
MISCELLANEOUS
15
State Contract Number / LGU Contract Number *
16
Total Persons Served
(OMH Only)
17
Total Units of Service
Gross Cost Per Unit
18
Net Cost Per Unit
19
20
Workshop Contract Sales
(Direct)
21
Local Government
(OASAS Only)
22
Voluntary Contributions
(OASAS Only)
* For direct contracts
enter the State contr
act
number. F
or ocal
l
county contr
act
enter the l
ocal
county contr ct number.
a
Revised
01-Apr-09
CQR-1.1

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