Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071439
Contract number
CTR071439
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking placements and transitions of individuals, likely in a foster care or youth services program. The spreadsheet is designed to capture detailed information about program participants, including personal identifiers, placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, and medical visits.

The report template provides a comprehensive tracking mechanism for monitoring individual progress, with multiple dropdown options for categorizing reasons for leaving (such as reunification, aged out, disruption), destination types (other group home, licensed foster home), extracurricular activities (sports team, academic club), and medical visits (urgent care, primary care, dental exams). The structured format suggests this is part of a standardized reporting process for a state or local human services agency to track outcomes and monitor the placement and transition of youth in care.

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Text version

GH_monthly Exhibit XVII

Quarterly Outcome ReportQuarter submitted:
Provider Name
Facility Name
Report Date
PIDLast NameFirst NameDate PlacedDate LeftReason for LeavingDestinationSchool NameDate Enrolled In SchoolExtracurriculars (select multiple)Medical Visits During Month (select multiple)Child Contact: # of visitsChild Contact: # of calls

options

Reason for LeavingExtracurricularsMedicalDisruptionDestination
Planned Transition to other out of home careSports TeamUrgent care visitN/AOther group home
ReunificationMusicPrimary Care Physicianwith 30 day noticeLicensed foster or kinship home
Aged outJobDental examwithout 30 day noticeHome (reunification)
Disruption w 30 day noticeAcademic clubDental procedureHigher level of care (HCTC, RTC)
Disruption w/o 30 day noticeArts programEmergency room visitHospital
RunawayCommunity club (Boys/Girl Scouts etcHospital visit (outpatient)Jail/Prison (arrest)
MilitaryOvernight hospitalizationAged Out
Student Leadership

File details come from the government source that posted it. Updated .