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 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 .