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DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> m.) Work Statement <br /> This form is used to document program activities, program goals, performance measures, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. <br /> e Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. SMART Goals <br /> o Performance Measures describe how you will evaluate the degree in which you achieved <br /> the stated goals. <br /> o Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. <br /> Actual Estimated Projected <br /> 2014-15 2015-16 2016-17 <br /> Program Activity 1 <br /> Program Goal Maintain Adult Day Health Maintain Adult Day Health Maintain Adult Day Health <br /> 1 "I -I I I III -# I • II-I -I <br /> Increase marketing <br /> Peilormance Measures <br /> Strategies Increase marketing Strategies Increase marketing Strategies <br /> Program Results Monthly Marketing resulted in Monthly Marketing resulted in an Monthly Marketing resulted in an <br /> .1 I 0-I I I I • II-# ". ". 11 -I It III <br /> Program Activity 2 Prevent and/or Delay Prevent and for Delay Prevent and for Delay <br /> Institutionalionalization Institutionalionalization Institutionalionalintion <br /> Program Goal rTesoopurrocveilti7navn:ioaflcooamarrilcuioniatynts rTesoopurrocvesidetof financial oa fl cooamitrincumniatynts To provide financial community <br /> resources to 85%of oarticivants <br /> Performance Measures Assist with supplemental Assist with supplemental funding Assist with supplemental funding <br /> .11-0 +11 I •I <br /> Program Results <br /> 25°0 of families resulted in 20%of families resulted in 15%of families resulted in <br /> I *O. .1 *zation, institutionalization <br /> Program Activity 3 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> Program Activity 4 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> Activity 5 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> Main Application 1/25/2016 12:26:51 PM Page 16 of 21 <br />