Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071450
Contract number
CTR071450
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report spreadsheet template for tracking youth placement and transition outcomes, likely related to a social services or foster care contract. While the specific state or agency is not clearly identified in the provided excerpt, the document seems designed for systematic reporting of individual case management information for youth in out-of-home care settings.

The template captures comprehensive data points including placement details, reasons for leaving a current placement, destination/transition information, medical visits, child contact frequency, extracurricular activities, and enrollment status. The report supports tracking placement stability, medical care, and educational engagement for youth, with multiple categorical options for documenting transitions such as reunification, placement in foster/kinship homes, higher levels of care, or other transition scenarios. The document appears structured to provide a standardized quarterly reporting mechanism for tracking individual youth outcomes across a care management system.

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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 .