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 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 .