Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071466
Contract number
CTR071466
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking spreadsheet for a social services or youth placement program. The template is designed to capture detailed monthly reporting information for individual participants, including placement details, school enrollment, medical visits, extracurricular activities, and reasons for leaving a current placement.

The report template includes multiple data collection fields such as participant identification, placement dates, destination tracking, school enrollment status, extracurricular involvement, medical visits, and contact frequency. The document provides predefined categorical options for tracking outcomes like reunification, transitions between care facilities, medical interactions, and reasons for program exit (e.g., aged out, disruption, runaway). The spreadsheet seems structured to support comprehensive monitoring and reporting for a youth services or foster care related program, enabling systematic documentation of individual participant progression and placement outcomes.

View the file

Other files

File Type Posted
Congregate_Care_Services_SOW_Amendment_2.pdf PDF
Contract_Amendment_2.pdf PDF
Exhibit I - DCS 06-01 Limited English Proficiency.pdf PDF
Exhibit II - Personalized Service Plan.pdf PDF
Exhibit VIII Personal Allowance Ledger.pdf PDF
Exhibit XVI Facility Modification Request.pdf PDF
Forced_Labor_of_Ethnic_Uyghurs_Ban.pdf PDF
Lic.KingFamilyHomes.11.25.2024.Amend_Redacted.pdf PDF
www.commercial.progressive.com_Redacted.pdf PDF
Contract_Amendment_6.pdf PDF
Lic.2024-2025.KingFamilyHomes.Amend_10.17.25__Redacted.pdf PDF
Opert.Cert.2024-2025.KingFamilyHomesII.Amend_10.17.25__Redacted.pdf PDF
Antoinette_and_Andrew_King_dba_King_Family_Home_Offer_and_Acceptance_Redacted.pdf PDF
Boycott_of_Israel_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_3.pdf PDF
Contract_Amendment_Special_Terms1.pdf PDF
Exhibit CS0-1015A.pdf PDF
Exhibit V - Blood Sugar Log.pdf PDF
Exhibit VII Clothing Allowance Ledger.pdf PDF
Exhibit X Returned Allowances Form.xlsx XLSX spreadsheet
Exhibit XV Discharge Summary.pdf PDF
Exhibit XXII ADJC Residential Services Invoice.docx DOCX document
ADCS_Business_HITECH.pdf PDF
COI_Redacted.pdf PDF
Certificate_6.1.2025_Redacted.pdf PDF
Congregate_Care_Services_Amendment.pdf PDF
Congregate_Care_Services_SOW_Amendment_1.pdf PDF
Exhibit IX Clothing and Property Inventory.pdf PDF
Exhibit VI Fees Log.pdf PDF
Exhibit XI One on One Supervision.pdf PDF
Exhibit XII Bed Hold.pdf PDF
Exhibit XIV Provider Census Report 2024.xlsm XLSM spreadsheet
Exhibit XVIII ADJC Monthly Attendance Report.doc DOC document
Congregate_Care_Services_Amendment_5.pdf PDF
Congregate_Care_Services_SOW_2024.pdf PDF
Contract_Extension.pdf PDF
Directions_to_Procurement_File.docx DOCX document
Exhibit III - Medication Log.pdf PDF
Exhibit IV - Medication Error Report.pdf PDF
Exhibit XIX ADJC Census Report.doc DOC document
Exhibit XX ADJC-5002 ADJC Service Providers Protocol ADJC.doc DOC document
King_Family_Homes_-COI_Redacted.pdf PDF
Show all 42

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

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 .