Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071443
Contract number
CTR071443
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report template for tracking youth placement, services, and outcomes, likely related to a state or local social services contract for foster care or youth support programs. The spreadsheet is designed to capture detailed information about individual youth, including placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, medical visits, and contact frequency.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions, medical care, educational engagement, and support services. It includes multiple dropdown options for tracking reasons for leaving a placement (such as reunification, aging out, or disruption), destination types (like foster homes or other group homes), medical visits (urgent care, dental, emergency room), and extracurricular activities. The document suggests a structured approach to documenting youth services, potentially for billing, performance tracking, or compliance purposes for a state or local human services agency.

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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 .