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 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 .