Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071448
Contract number
CTR071448
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a tracking and reporting template for a social services or foster care placement program. The file is a Microsoft Excel spreadsheet designed to capture detailed information about individual placements, including participant demographics, placement details, and transition outcomes.

The template tracks comprehensive placement metrics including participant details such as placement dates, reasons for leaving, destination information, school enrollment, extracurricular activities, medical visits, and contact frequency. The report seems structured to monitor transitions between care settings, with options for tracking moves to other group homes, reunification, foster/kinship homes, and other placement scenarios. The form includes multiple dropdown options for reasons for leaving, medical encounters, extracurricular involvement, and destination placements, suggesting a standardized tracking system for youth services or foster care management.

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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 .