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 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 .