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 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 .