Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071407
Contract number
CTR071407
Issued by
Arizona

About this file

This document appears to be an Excel-based quarterly reporting template for a youth services or foster care tracking system, specifically an Exhibit XVII Quarterly Outcome Report. The template is designed to capture detailed information about placed youth, including their placement status, transitions, medical interactions, school enrollment, and contact frequency. While the specific state or agency is not clearly identified in the provided excerpt, the document seems to be a standardized reporting mechanism for tracking youth placement and support services.

The template captures comprehensive data points including personal identifiers, placement dates, reasons for leaving a placement, destination details, school enrollment, extracurricular activities, medical visits, and contact metrics. The report allows for tracking multiple transition scenarios such as reunification, placement in other group homes, licensed foster/kinship homes, and tracking reasons for disruption with or without notice. Medical tracking includes primary care, dental, urgent care, and emergency room visits. The document appears to be a robust monitoring tool for youth services programs, enabling detailed tracking of individual youth outcomes and transitions across various 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 .