Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071441
Contract number
CTR071441
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking document for a human services or youth placement program. The file contains a template for reporting details about individual case management, including placements, transitions, medical visits, school enrollment, and other critical tracking information for youth in out-of-home care settings.

The report template provides comprehensive fields for tracking individual participant outcomes, including placement date, reason for leaving, destination, school enrollment, extracurricular activities, medical visits, and contact interactions. The document supports monitoring transitions between care settings such as group homes, foster/kinship care, reunification, and other placement types, with specific attention to medical care, educational engagement, and youth support services. The spreadsheet is designed to capture granular data about each participant's placement trajectory, medical interactions, and overall case management progress.

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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 .