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 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 .