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 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 .