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 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 .