Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071415
Contract number
CTR071415
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking spreadsheet for monitoring placement, transitions, and outcomes for youth in a care management or foster care program. The template is designed to capture detailed individual-level data including placement dates, reasons for leaving, destination, school enrollment, medical visits, child contact frequency, and extracurricular activities.

The report template provides a comprehensive tracking mechanism for monitoring youth transitions across various care settings, including group homes, foster/kinship placements, and reunification scenarios. It captures multiple data points such as medical interactions (urgent care, primary care, dental visits), educational engagement, contact frequency with children, and reasons for placement changes. The spreadsheet allows for multi-select options in categories like extracurricular activities, medical visits, and reasons for leaving, suggesting a flexible and detailed approach to tracking youth placement and transition outcomes.

View the file

Other files

File Type Posted
Congregate_Care_Services_Amendment.pdf PDF
Exhibit V - Blood Sugar Log.pdf PDF
Exhibit VI Fees Log.pdf PDF
Exhibit VII Clothing Allowance Ledger.pdf PDF
Exhibit X Returned Allowances Form.xlsx XLSX spreadsheet
Exhibit XII Bed Hold.pdf PDF
Exhibit XX ADJC-5002 ADJC Service Providers Protocol ADJC.doc DOC document
Exhibit XVI Facility Modification Request.pdf PDF
Congregate_Care_Services_SOW_Amendment_2.pdf PDF
Contract_Amendment_Special_Terms.pdf PDF
Exhibit III - Medication Log.pdf PDF
Exhibit VIII Personal Allowance Ledger.pdf PDF
Exhibit XI One on One Supervision.pdf PDF
Exhibit XIX ADJC Census Report.doc DOC document
Exhibit XXII ADJC Residential Services Invoice.docx DOCX document
ArizonaDepartmentofChildSafety18162276__1__Redacted.pdf PDF
COI_AZDCS_ArizonaDepartmentofChildSafety6635434_Redacted.pdf PDF
Congregate_Care_Services_SOW_2024.pdf PDF
Directions_to_Procurement_File.docx DOCX document
Exhibit CS0-1015A.pdf PDF
Exhibit II - Personalized Service Plan.pdf PDF
Exhibit IX Clothing and Property Inventory.pdf PDF
Exhibit XIV Provider Census Report 2024.xlsm XLSM spreadsheet
Exhibit XV Discharge Summary.pdf PDF
Exhibit XVIII ADJC Monthly Attendance Report.doc DOC document
Offer_and_Acceptance_Courageux_Redacted.pdf PDF
2-3D_Boycott_of_Israel_Disclosure_Redacted.pdf PDF
2-3E_Forced_Labor_of_Ethnic_Uyghurs_Ban_Redacted.pdf PDF
Congregate_Care_Services_SOW_Amendment_1.pdf PDF
Courageux_HITECH.pdf PDF
Exhibit I - DCS 06-01 Limited English Proficiency.pdf PDF
Exhibit IV - Medication Error Report.pdf PDF
Show all 32

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file

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 .