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 Report | Quarter submitted: | |||||||||||
| Provider Name | ||||||||||||
| Facility Name | ||||||||||||
| Report Date | ||||||||||||
| PID | Last Name | First Name | Date Placed | Date Left | Reason for Leaving | Destination | School Name | Date Enrolled In School | Extracurriculars (select multiple) | Medical Visits During Month (select multiple) | Child Contact: # of visits | Child Contact: # of calls |
options
| Reason for Leaving | Extracurriculars | Medical | Disruption | Destination |
| Planned Transition to other out of home care | Sports Team | Urgent care visit | N/A | Other group home |
| Reunification | Music | Primary Care Physician | with 30 day notice | Licensed foster or kinship home |
| Aged out | Job | Dental exam | without 30 day notice | Home (reunification) |
| Disruption w 30 day notice | Academic club | Dental procedure | Higher level of care (HCTC, RTC) | |
| Disruption w/o 30 day notice | Arts program | Emergency room visit | Hospital | |
| Runaway | Community club (Boys/Girl Scouts etc | Hospital visit (outpatient) | Jail/Prison (arrest) | |
| Military | Overnight hospitalization | Aged Out | ||
| Student Leadership |
File details come from the government source that posted it. Updated .