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 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 .