Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071444
Contract number
CTR071444
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a standardized tracking form for monitoring placements and outcomes for youth in care, likely within a state social services or child welfare system. The spreadsheet template is designed to capture detailed information about individual cases, including placement details, reasons for leaving, destination, school enrollment, medical visits, and extracurricular activities.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions, with multiple dropdown options for tracking placement changes, medical interactions, and program engagement. Key tracking categories include placement destinations (such as other group homes, licensed foster care, reunification), reasons for leaving (disruption, planned transition), medical visits (urgent care, dental, emergency room), and extracurricular involvement (sports teams, academic clubs, community organizations). The document suggests a structured approach to monitoring youth placement outcomes and tracking their progress through various care and support systems.

View the file

Other files

File Type Posted
2-Attachment_3-E___PHYF_1_Redacted.pdf PDF
Award_Letter-Power_House_Youth_Facility_Redacted.pdf PDF
COIs_ACORD_Form_2025_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_1.pdf PDF
Congregate_Care_Services_SOW_Amendment_3.pdf PDF
Directions_to_Procurement_File.docx DOCX document
Exhibit I - DCS 06-01 Limited English Proficiency.pdf PDF
Exhibit II - Personalized Service Plan.pdf PDF
Exhibit XV Discharge Summary.pdf PDF
Exhibit XVIII ADJC Monthly Attendance Report.doc DOC document
2-Attachment_3-D__PHYF_Redacted.pdf PDF
Business_associate_Agreement_HITECH-signed.pdf PDF
COI_Worker_Comp-_State_of_Arizona_DCS_-_2024_05_08_Redacted.pdf PDF
Congregate_Care_Services_Amendment_4.pdf PDF
Congregate_Care_Services_SOW_2024_with_Terms_and_Conditions.pdf PDF
Contract_Amendment_3.pdf PDF
Exhibit IV - Medication Error Report.pdf PDF
Exhibit XVI Facility Modification Request.pdf PDF
License_and_Op_Cert_Redacted.pdf PDF
Offer_and_Acceptance_Redacted.pdf PDF
COI_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_2.pdf PDF
Exhibit VI Fees Log.pdf PDF
Exhibit XI One on One Supervision.pdf PDF
Exhibit XII Bed Hold.pdf PDF
Exhibit XIX ADJC Census Report.doc DOC document
Exhibit XX ADJC-5002 ADJC Service Providers Protocol ADJC.doc DOC document
ACORD_Form_20250122-093822_Redacted.pdf PDF
COIJune2025_Redacted.pdf PDF
Congregate_Care_Services_Amendment.pdf PDF
Contract_Amendment_1.pdf PDF
Exhibit CS0-1015A.pdf PDF
Exhibit III - Medication Log.pdf PDF
Exhibit IX Clothing and Property Inventory.pdf PDF
Exhibit V - Blood Sugar Log.pdf PDF
Exhibit VII Clothing Allowance Ledger.pdf PDF
Exhibit VIII Personal Allowance Ledger.pdf PDF
Exhibit X Returned Allowances Form.xlsx XLSX spreadsheet
Exhibit XIV Provider Census Report.xlsm XLSM spreadsheet
Exhibit XXII ADJC Residential Services Invoice.docx DOCX document
Show all 40

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

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 .