Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071422
Contract number
CTR071422
Issued by
Arizona

About this file

This document appears to be an Exhibit XVII Quarterly Report spreadsheet template for tracking placement and outcomes of individuals, likely in a social services or foster care program. The file contains detailed tracking fields for reporting on individual placements, including personal identifiers, placement dates, reasons for leaving, destinations, school enrollment, extracurricular activities, medical visits, and contact information.

The spreadsheet provides a comprehensive tracking mechanism for monitoring individual progress, transitions, and outcomes across various categories such as living arrangements (group homes, foster/kinship homes), educational engagement, medical interactions, and contact frequency. The template allows for multiple selection of reasons for leaving, destination types, extracurricular activities, and medical visits, suggesting a flexible and detailed reporting approach for tracking individual service recipient movements and experiences within a social service or care management 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 .