Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071423
- Contract number
- CTR071423
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report template, a tracking spreadsheet for a state or local government program related to youth placement and services. The spreadsheet is designed to capture detailed information about individual cases, including placement details, transitions, medical visits, child contact, and reasons for leaving a current placement.
The report template includes columns for tracking comprehensive information such as provider name, facility name, personal identification (PID), participant demographics, placement dates, reasons for leaving, destination details, school enrollment, extracurricular activities, medical visits, and contact metrics. The form seems structured to monitor youth transitions between care facilities, educational settings, and potential reunification scenarios, with specific attention to medical care, school engagement, and support service tracking.
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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 .