Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071424
- Contract number
- CTR071424
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking document for a social services or youth placement program. The file contains a template for reporting detailed information about individual participants, including their placement status, school enrollment, medical visits, contact frequency, reasons for leaving a program, and destination after leaving.
While the document does not provide specific contract details, it suggests a comprehensive tracking mechanism for a youth services program, likely related to foster care, group home placement, or transitional housing. The report template captures critical data points such as placement dates, reasons for leaving, school enrollment, extracurricular activities, medical visits, and subsequent living arrangements. The form allows for multiple selection of categories like destination (e.g., reunification, other group home, licensed foster home), reasons for leaving, and medical interactions, indicating a structured approach to monitoring individual participant outcomes and transitions.
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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 .