Schedule Cqr-1 - Consolidated Quarterly Report - Office Of Mental Health Of New York State Page 2
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1
2OASAS
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):
Page
_____1st
_____2nd
_____3rd
_____Mid-Year
REVISION #_____
AGENCY NAME:__________________________________________________
AGENCY CODE: ________________________________
LGU:____________________________________
PREPARED BY:__________________________________________________
COUNT NAM AND CODE: _____________________ (
Y
E
)
LGU APPROVAL BY:____________________________________
TELEPHONE:__________________________________________________
USE WHOLE DOLLARS ONLY
COLUMN NUMBER
1
2
3
4
5
6
7
PROGRAM TY
PE
PROGRAM TYPE
PROGRAM TYPE
PROGRAM TYPE
SERVICE PROVIDER
SERVICE PROVIDER
(
)
(
)
(
)
(
)
Line
ITEM DESCRIPTION
STATE AGENCY
YEAR-TO-DATE
TOTAL
CODE
INDEX
CODE
INDEX
CODE
INDEX
CODE
INDEX
No.
APPROVED BUDGET
TOTAL
FOR THIS QUARTER
A.
23
Funding Code
Direct Contract # (If Applicable)
24
Local Contract # (If Applicable)
25
26
No. Persons Served
(OMH Only)
27
27
Units of Service
Units of Service
Total Expenses
28
29
Revenue:Medicaid
30
Revenue:Other
Total Revenues
31
Net Operating Costs
32
33
B.
Funding Code
34
Direct Contract # (If Applicable)
Local Contract # (If Applicable)
35
36
No. Persons Served
(OMH Only)
37
Units of Service
38
Total Expenses
Revenue:Medicaid
39
40
Revenue:Other
41
Total Revenues
Net Operating Costs
42
C.
Funding Code
43
44
Direct Contract # (If Applicable)
45
Local Contract # (If Applicable)
46
No. Persons Served
(OMH Only)
47
Units of Service
48
Total Expenses
49
49
R
Revenue:Medicaid
M di
id
Revenue:Other
50
51
Total Revenues
52
Net Operating Costs
D.
53
Funding Code
Direct Contract # (If Applicable)
54
55
Local Contract # (If Applicable)
56
No. Persons Served
(OMH Only)
Units of Service
57
58
Total Expenses
59
Revenue:Medicaid
Revenue:Other
60
Total Revenues
61
62
Net Operating Costs
Revised
01-Apr-09
CQR-1.2
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