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 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 .