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 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 .