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.
View the file
Other files
Show all 34
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 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 .