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 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 .