Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071405
Contract number
CTR071405
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking youth placement and transition data, likely related to a state or local social services contract. The spreadsheet is designed to capture detailed information about individual placements, including personal identifiers, placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, and medical visits.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions across different care settings, including group homes, foster care, kinship care, and other out-of-home placement options. The document includes multiple dropdown options for tracking reasons for leaving (such as reunification, aging out, disruption), destination types, extracurricular involvement, medical encounters, and contact frequency. While the specific contract details are not fully visible, the document suggests a structured approach to monitoring youth services and placement outcomes, potentially for a state human services or child welfare agency.

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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 .