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 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 .