Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071413
Contract number
CTR071413
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template, which is a standardized tracking document for a youth services or placement program. The template is designed to capture detailed information about individual placements, including participant demographics, placement details, reasons for leaving, destination, school enrollment, medical visits, and other programmatic metrics.

The report template includes multiple fields for tracking critical information such as placement dates, reasons for leaving (e.g., reunification, aging out, disruption), destination types (other group home, licensed foster home), school enrollment, extracurricular activities, and medical encounters. The form provides comprehensive data collection capabilities for monitoring youth transitions, care continuity, and program outcomes, suggesting this is likely a state or local government human services contract for 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 .