Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071432
- Contract number
- CTR071432
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking template for a youth services or foster care program. The spreadsheet is designed to capture detailed information about placed youth, including their placement status, medical interactions, school enrollment, extracurricular activities, and reasons for transitioning between care environments.
The report template provides comprehensive tracking mechanisms for monitoring individual youth placements, with multiple categorical options for documenting placement changes, medical visits, child contact frequencies, reasons for leaving a placement, and destination outcomes. The spreadsheet includes columns to record detailed information such as placement dates, school enrollment, medical visits (including urgent care, primary care, dental exams), extracurricular participation, and transition destinations like reunification, other group homes, licensed foster care, or higher levels of care. The form appears to be a standardized reporting instrument for tracking youth services program outcomes and movements within the care system.
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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 .