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 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 .