Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071449
Contract number
CTR071449
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report spreadsheet template for tracking youth placement and outcomes, likely related to a social services or foster care contract. The file contains detailed tracking fields for individual client information, including placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, and medical visits.

The spreadsheet includes comprehensive tracking categories for youth transitions, including destination types (e.g., other group homes, licensed foster homes, reunification), reasons for leaving (such as disruption, aging out), and detailed medical and educational contact information. The template seems designed to capture holistic case management data for tracking placement outcomes, medical interactions, educational engagement, and client movement between care settings, suggesting it is a monitoring tool for a state-level human services or youth placement program.

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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 .