Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071426
Contract number
CTR071426
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report template for tracking youth placement and transition outcomes, likely related to a state or local government social services contract. The spreadsheet is designed to capture detailed information about individual youth placements, including personal identification, placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, and medical visits.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions across various care settings, including group homes, foster/kinship care, reunification, and other placement types. It includes multiple categorical fields for documenting reasons for leaving (such as disruption, planned transition, or aging out), destination details, school enrollment, extracurricular participation, and medical interactions. The structured format suggests this is part of a standardized reporting process for a state or local human services agency managing youth placement and support services, with a focus on tracking individual outcomes and transitions between care environments.

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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 .