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 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 .