Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071406
Contract number
CTR071406
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which seems to be a tracking document for a social services or youth placement program. The spreadsheet template is designed to capture detailed information about individual placements, including client demographics, placement details, reasons for leaving, destination, school enrollment, medical visits, and contact information.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions between care facilities, educational settings, and living arrangements. It includes columns for tracking key metrics such as placement dates, reasons for leaving (e.g., reunification, aging out, disruption), destination types (foster homes, other group homes), school enrollment, extracurricular activities, and medical visits. The document suggests a structured approach to monitoring and reporting on youth placement outcomes, likely for a state or local human services agency responsible for tracking and supporting youth in out-of-home care settings.

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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 .