Exhibit XVII Quarterly Report.xlsm
XLSM spreadsheet 18 KB Posted
- Attached to
- Master Agreement AZ|CTR071445
- Contract number
- CTR071445
- Issued by
- Arizona
About this file
The document appears to be an Exhibit XVII Quarterly Outcome Report, which is a template for tracking placement, enrollment, and transition data for individuals in a care or support program. The spreadsheet contains fields for reporting demographic and service-related information, including provider name, facility name, personal identification details, placement dates, reasons for leaving, destination, school enrollment, extracurricular activities, and medical visits.
The report template suggests a comprehensive tracking mechanism for monitoring individual progress and transitions across various care settings, including group homes, foster care, kinship care, and other out-of-home placements. The document captures detailed information about each individual's status, including reasons for program exit (such as reunification, aging out, or disruption), educational engagement, medical interactions, and contact frequency. While specific pricing, contract terms, or jurisdictional details are not evident in this document, the template indicates a structured approach to monitoring and reporting on individual placement and support services.
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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 .