Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071416
- Contract number
- CTR071416
- Issued by
- Arizona
About this file
The document appears to be an Excel-based quarterly reporting template for a social services or foster care tracking system, specifically an Exhibit XVII Quarterly Outcome Report. The template is designed to capture detailed information about youth placement, movement, and service interactions, but the specific government agency or jurisdiction is not clearly identified in the provided file excerpt.
The reporting template includes comprehensive tracking fields for individual youth, including placement dates, reasons for leaving a facility, destination details, school enrollment, extracurricular activities, medical visits, and contact frequency. Key tracking categories include destination types (such as other group homes, reunification, licensed foster homes), reasons for leaving (like disruption, planned transition), medical interactions (urgent care, dental exams, emergency room visits), and extracurricular involvement (sports teams, academic clubs, community organizations). The document seems structured to monitor and report on youth transitions and service engagement, suggesting it is part of a structured social services or child welfare program tracking mechanism.
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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 .