Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071411
Contract number
CTR071411
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report template, a standardized form for tracking placement, enrollment, and outcomes for youth in out-of-home care settings. The spreadsheet is designed to capture detailed individual-level data about participants, including demographic information, placement status, school enrollment, medical visits, extracurricular activities, and reasons for transitions between care environments.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions, with multiple categorical options for reporting destinations, reasons for leaving a placement, medical interactions, and engagement in activities. The document includes columns for tracking placement dates, school enrollment, contact frequency, medical visits (such as primary care, dental, urgent care, emergency room), and potential transition scenarios like reunification, moving to another group home, foster care, or aging out of the system. The form appears to be a data collection tool for monitoring and reporting on youth welfare and placement outcomes across different care settings.

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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 .