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 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 .