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DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 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 /> • 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 /> • Performance Measures describe how you will evaluate the degree in which you achieved
<br /> the stated goals.
<br /> • Actual Program Results use program results to indicate the actual measureable
<br /> achievement of goals. If goals were not met, please explain.
<br /> (Please See Attached)
<br /> Actual Estimated Projected
<br /> 2014-2015 2015-2016 2016-2017
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<br /> Program Activity 1
<br /> Program Goal
<br /> Performance Measures
<br /> Program Results
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<br /> Program Activity 2
<br /> Program Goal
<br /> Performance Measures
<br /> Program Results
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<br /> Program Activity 3
<br /> Program Goal
<br /> Performance Measures
<br /> Program Results
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<br /> Program Activity 4
<br /> Program Goal
<br /> Performance Measures
<br /> Program Results
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<br /> Program Activity 5
<br /> Program Goal
<br /> Performance Measures
<br /> Program Results
<br /> Main Application 1/25/2016 11:36:35 AM Page 11 of 1 6
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