Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071452
- Contract number
- CTR071452
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which seems to be a tracking document for a social services or foster care program. The file contains a template for reporting detailed information about youth placements, transitions, medical interactions, and other service-related metrics. While the specific jurisdictional details are not fully clear from the excerpt, the document suggests a standardized reporting mechanism for tracking individual youth outcomes across multiple care environments.
The report template captures comprehensive data points including placement dates, reasons for leaving a care facility, destination details, school enrollment, extracurricular activities, medical visits, and contact frequency. The form allows for multiple selection of categories such as reasons for leaving (e.g., reunification, aged out, disruption), destination types (other group home, licensed foster home), medical interactions (urgent care, dental exams), and extracurricular involvement (sports teams, academic clubs). The systematic nature of the document indicates a structured approach to monitoring and reporting youth service program outcomes, though specific contract value, pricing terms, or jurisdictional boundaries are not evident in this excerpt.
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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 .