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 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 .