Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071425
Contract number
CTR071425
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking document for a youth services or foster care placement program. The file contains a detailed template for reporting individual placements, transitions, and outcomes for youth in out-of-home care settings. The spreadsheet includes columns for tracking personal identification, placement dates, reasons for leaving, destination, school enrollment, medical visits, child contact frequency, and extracurricular activities.

The report template suggests a comprehensive monitoring system for youth placement services, with multiple potential outcomes and transition scenarios including reunification, placement in foster/kinship homes, higher levels of care, and tracking of medical, educational, and social engagement metrics. The document provides a structured mechanism for reporting on individual youth outcomes, potentially for a state or local government human services agency managing foster care or youth support programs. The detailed tracking allows for granular assessment of placement effectiveness, medical and educational engagement, and transition management for youth in care.

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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 .