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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA 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 <br /> accomplish its program goals. <br /> • Program Goal should explain what the program is trying to achieve/accomplish. <br /> Goals are statements about what the program should accomplish. SMART Goals <br /> • Performance Measures describe how you will evaluate the degree in which you <br /> achieved 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 /> ACTUAL ESTIMATED PROJECTED <br /> 2014-15 2015-16 2016-17 <br /> Program Activity 1 <br /> Program Goal To provide academic & tutoring <br /> assistance for at-risk youth to improve <br /> grades. <br /> Performance Measures Report Cards <br /> Program Results To increase grades in Reading and/or <br /> Math by 1 point (on the scale of 1-4) <br /> for 20% of the youth members. <br /> Program Activity 2 <br /> Program Goal To monitor personal & social skills of <br /> program members to increase <br /> development of positive behaviors <br /> Program Measures Report Cards —4 categories: <br /> 1) Follows classroom rules <br /> 2) Takes responsibility for behavior & <br /> actions <br /> 3) Respects & cooperates with others <br /> 4) Follows directions <br /> Program Results 75% of members will meet the <br /> standards set by schools in 4 of 14 <br /> categories. <br /> Main Application 5/24/2016 8:59:25 a5/p5 P 16 o of 23 <br />