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 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 .