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 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 .