Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071431
Contract number
CTR071431
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template, which seems to be related to a social services or youth placement tracking system. The file contains fields for documenting individual client placements, transitions, medical visits, extracurricular activities, and reasons for leaving a current placement or program.

The report template includes detailed tracking columns for monitoring individual client status, including personal identification information, placement dates, destination details, school enrollment, medical interactions, child contact frequency, reasons for leaving a program, and extracurricular participation. The comprehensive tracking mechanism suggests this is likely part of a state or local government human services contract for monitoring youth in care, potentially focusing on foster care, group home, or transitional housing programs. The granular data collection indicates a systematic approach to tracking client outcomes and movements within a social service delivery system.

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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 .