Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071410
- Contract number
- CTR071410
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report template for tracking placement and service details for youth in a care or foster program. The spreadsheet is designed to capture comprehensive information about individual participants, including their placement status, contact interactions, reasons for leaving a program, medical visits, and educational engagement.
The report template includes columns for tracking critical data points such as participant personal identification, facility details, placement dates, reasons for leaving, destination information, school enrollment, extracurricular activities, medical visits, and contact frequency. The document seems to be a standardized reporting mechanism for monitoring youth transitions, medical care, educational progress, and overall program outcomes, likely used by a state or local government agency responsible for youth services or foster care management.
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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 .