Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071434
Contract number
CTR071434
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking spreadsheet for a social services or youth placement program. The file contains detailed tracking information for individual placements, likely related to foster care, group home, or youth services tracking across multiple facilities and providers.

The report template captures comprehensive data points including participant demographics, placement details, reasons for leaving a current placement, destination information, school enrollment, medical visits, child contact frequency, extracurricular activities, and transition status. The spreadsheet provides fields for tracking medical interactions (such as primary care, dental, urgent care, emergency room visits), educational engagement, and placement transitions including moves to other group homes, reunification, foster care, or other out-of-home care settings. The document seems designed to monitor individual youth outcomes and track movement between different care and support environments.

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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 .