Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071429
- Contract number
- CTR071429
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking placement and transition data for youth in care, likely related to a social services or foster care contract. While the specific state or agency is not explicitly named in the provided excerpt, the document seems designed for systematic reporting of individual client movements, placement changes, and key life events.
The reporting template captures comprehensive details including client personal identification, placement dates, reasons for leaving a current placement, destination information, school enrollment status, medical interactions, child contact frequency, extracurricular activities, and transition outcomes. The form provides multiple dropdown options for scenarios such as reunification, placement in alternative care settings, aging out of the system, medical visits, and reasons for program disruption. The structured nature of the document suggests it is part of a standardized tracking and reporting mechanism for youth services, potentially used for performance monitoring and program evaluation.
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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 .