Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071409
Contract number
CTR071409
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking placement and transition data for youth in a care or placement program. The spreadsheet seems designed for tracking individual participant details, including demographic information, placement dates, reasons for leaving, destination, school enrollment, medical visits, and contact interactions.

The report template includes multiple categorical fields for tracking outcomes such as placement transitions (e.g., reunification, other group home, licensed foster care), medical interactions (urgent care, primary care, dental visits), extracurricular activities (sports teams, academic clubs, community organizations), and reasons for leaving a current placement. The document appears to be a standardized reporting tool for monitoring youth placement services, likely used by a state or local social services agency to track individual case management and transition outcomes.

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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 .