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 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 .