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 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 .