Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071438
- Contract number
- CTR071438
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking spreadsheet for placement and service data related to youth in out-of-home care or foster care settings. The template is designed to capture comprehensive monthly tracking information about individual youth, including placement details, reasons for leaving a facility, destination, school enrollment, medical visits, and child contact interactions.
The report template provides a structured mechanism for monitoring youth transitions between care facilities, tracking medical and educational engagement, and documenting key life events such as reunification, placement changes, or aging out of the system. The spreadsheet includes multiple dropdown fields for reporting categories like reason for leaving, destination, extracurricular activities, medical visits, and contact frequency, suggesting it is part of a standardized reporting process for a state or local human services agency responsible for youth care and placement oversight.
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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 .