Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071419
- Contract number
- CTR071419
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking placement, enrollment, and transition data for youth in out-of-home care settings. While the specific state or agency is not clearly identified in the excerpt, the document is structured as a detailed tracking mechanism for monitoring individual placements, transitions, medical interactions, and educational engagement for youth in care.
The template captures comprehensive information including placement dates, reasons for leaving a facility, destination details, school enrollment, extracurricular activities, medical visits, and contact frequency. The report seems designed to track multiple dimensions of youth placement, including transitions between care settings (such as group homes, foster/kinship homes), medical interactions (primary care, dental, urgent care, emergency room visits), educational engagement, and potential disruptions in placement. The form allows for multiple selection of categories across medical visits, extracurricular activities, and reasons for leaving, suggesting a flexible and detailed tracking approach for youth services and placement management.
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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 .