Exhibit XVII Quarterly Report.xlsm

XLSM spreadsheet 18 KB Posted

Attached to
Master Agreement AZ|CTR071447
Contract number
CTR071447
Issued by
Arizona

About this file

The document appears to be an Exhibit XVII Quarterly Report spreadsheet template for tracking placement and outcomes of youth in a care or foster program. The file seems to be related to a state or local government social services contract, designed to capture detailed monthly tracking information about individual participants, including placement details, reasons for leaving, medical visits, and destination status.

The spreadsheet includes comprehensive tracking fields such as participant personal identifiers, placement and departure dates, reasons for leaving (e.g., reunification, disruption, aged out), destination information, school enrollment status, extracurricular activities, medical visits, and contact metrics. The template suggests a structured reporting mechanism for monitoring youth transitions and care outcomes, likely used by a state agency or social services provider to document and analyze placement effectiveness and participant progress through various care or foster programs.

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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 .