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.
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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 .