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 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 .