Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071417
Contract number
CTR071417
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report spreadsheet template designed for tracking placement and outcomes for youth in care, likely within a state social services or foster care system. The spreadsheet is structured to capture detailed monthly reporting information about individual clients, including placement details, reasons for leaving, destination, school enrollment, medical visits, and extracurricular activities.

The template provides comprehensive tracking mechanisms for monitoring youth transitions, including categories for placement destinations such as reunification, other group homes, licensed foster or kinship homes, and tracking reasons for leaving like disruption, aging out, or planned transitions. The report includes fields for documenting medical interactions (urgent care, primary care, dental exams), school enrollment, extracurricular participation, and child contact metrics through visits and calls. While the specific state or agency is not explicitly identified in the excerpt, the document appears to be a standardized reporting tool for monitoring youth placement and support services.

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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 .