Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071437
- Contract number
- CTR071437
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report template, which is a monitoring and tracking document for a youth services or foster care program. The file is a Microsoft Excel spreadsheet designed to capture detailed information about individual placements, transitions, and outcomes for youth in a care or support program.
The report template includes comprehensive tracking fields for key metrics such as placement dates, reasons for leaving, destination information, school enrollment, extracurricular activities, medical visits, and child contact frequency. The form enables systematic documentation of youth transitions between care settings, including movements to other group homes, reunification, foster/kinship homes, or higher levels of care. The template allows for multiple selection of categories like medical visits (urgent care, dental, emergency room), extracurricular activities (sports, music, academic clubs), and reasons for program exit, providing a structured approach to monitoring youth placement and support services.
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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 .