Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071430
Contract number
CTR071430
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template, which seems to be a tracking document for a youth services or foster care placement program. The spreadsheet is designed to capture detailed information about individual placements, including participant demographics, placement status, transitions, medical interactions, and educational engagement.

The report template includes columns for tracking critical information such as participant personal identification, placement dates, reasons for leaving a current placement, destination details, school enrollment, extracurricular activities, medical visits, and contact frequency. The document appears to be a standardized reporting tool for monitoring youth transitions between care facilities, educational settings, and potential reunification or alternative placement scenarios, with specific attention to medical, educational, and social support metrics.

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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 .