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.

View the file

Other files

File Type Posted
2-Attachment_3-D__Boycott_of_Israel_Disclosure_1_Redacted.pdf PDF
COI_Exp_9-4-2026_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_1.pdf PDF
Contract_Amendment_1.pdf PDF
Exhibit I - DCS 06-01 Limited English Proficiency.pdf PDF
Exhibit IX Clothing and Property Inventory.pdf PDF
Exhibit VIII Personal Allowance Ledger.pdf PDF
Exhibit XII Bed Hold.pdf PDF
2-Attachment_3-E___Forced_Labor_of_Ethnic_Uyghurs_Ban_1_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_2.pdf PDF
Debra_s_Place_ACORD_2025-2026_Auto_Redacted.pdf PDF
Directions_to_Procurement_File.docx DOCX document
Exhibit CS0-1015A.pdf PDF
Exhibit VI Fees Log.pdf PDF
Exhibit VII Clothing Allowance Ledger.pdf PDF
Exhibit XVI Facility Modification Request.pdf PDF
Exhibit XVIII ADJC Monthly Attendance Report.doc DOC document
Congregate_Care_Services_Amendment_5.pdf PDF
Congregate_Care_Services_SOW_2024.pdf PDF
Contract_Amendment_Special_Terms.pdf PDF
Contract_Extension.pdf PDF
Debra_s_Place-Auto_Insurance_05122026_Redacted.pdf PDF
Debra_s_Place_ADCS_Business_Associate_Agreement_with_HITECH.pdf PDF
Debra_s_Place_Cert_Redacted.pdf PDF
Debra_s_Place_Insurance_ACORD_Redacted.pdf PDF
Debras_Place_ACORD_2025_expires_9-4-2025_Redacted.pdf PDF
Exhibit II - Personalized Service Plan.pdf PDF
Exhibit III - Medication Log.pdf PDF
Exhibit IV - Medication Error Report.pdf PDF
Exhibit V - Blood Sugar Log.pdf PDF
Exhibit X Returned Allowances Form.xlsx XLSX spreadsheet
Exhibit XIX ADJC Census Report.doc DOC document
Exhibit XV Discharge Summary.pdf PDF
Exhibit XXII ADJC Residential Services Invoice.docx DOCX document
Congregate_Care_Services_Amendment.pdf PDF
Congregate_Care_Services_SOW_Amendment_3.pdf PDF
Debras_Place_Cert._2025-2026_Redacted.pdf PDF
Exhibit XI One on One Supervision.pdf PDF
Exhibit XIV Provider Census Report 2024.xlsm XLSM spreadsheet
Exhibit XX ADJC-5002 ADJC Service Providers Protocol ADJC.doc DOC document
Offer_and_Acceptance_Redacted.pdf PDF
Show all 41

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

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 .