Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071412
- Contract number
- CTR071412
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a template for tracking placement, transition, and care details for individuals in a care or placement program. The spreadsheet is designed to capture comprehensive information about individuals, including their placement dates, reasons for leaving, destination, school enrollment, extracurriculars, medical visits, and contact interactions.
The report template provides a structured method for tracking multiple data points related to individual placements, including transitions between care facilities, school enrollment, medical interactions, and reasons for program exit. The document includes dropdown options for various scenarios such as destination types (e.g., other group home, licensed foster home, reunification), reasons for leaving (e.g., disruption, aged out), extracurricular activities, and medical visits. The form appears to be used for monitoring and reporting on individual progress and transitions within a care or placement system, likely for a state or local human services agency.
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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 .