Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071420
Contract number
CTR071420
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report spreadsheet template related to a youth services or foster care tracking system. The file seems designed to capture detailed placement, enrollment, and transition information for individual youth participants, potentially across a state or regional child welfare program.

The template includes comprehensive tracking fields for participant demographics, placement details, reasons for leaving a current placement, destination information, school enrollment status, medical visits, child contact frequency, extracurricular activities, and transition outcomes. The spreadsheet provides a standardized mechanism for monitoring individual youth progression through various care settings, including group homes, foster/kinship placements, and potential reunification scenarios. While specific pricing, contract terms, or jurisdictional details are not evident in this document, the template suggests a structured approach to tracking youth services and placement 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 .