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DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 /> Actual Estimated Projected <br /> 2014-2015 2015-2016 2016-2017 <br /> I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I 111 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 111 I I I I I I I I I I I I I I I 111 I I I I I I h I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I <br /> Program Activity 1 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> Program Activity 2 <br /> Program Goal <br /> Performance Measures. <br /> Program Results <br /> M111111111111111111111111111111.101 <br /> Program Activity 3 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> 3313131313131313131313111111313111111113333333311111331HEINEMEMMENNEMIMEINIMMEMMIEIMI <br /> Program Activity 4 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> 1111111111I .111 , <br /> Program Activity 5 <br /> Program Goal <br /> Performance Measures <br /> Program Results <br /> Main Application 5/25/2016 10:17:47 AM Pa 12 of 2 <br />