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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> m) Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities,program goals, performance measures, and <br /> actual results. (Add more rows as needed) If this is a new program, you will only document the <br /> projected information. Every program is required to have AT LEAST 1 Program Activity, which <br /> should be SMART (Specific, Measurable, Achievable, Relevant, and Time--bound. Click on <br /> SMART Goals to [earn more. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. (i.e. Deliver 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved the <br /> stated goals. (/.e. Will track the number of meals delivered each day) <br /> • Actual Program Results use program results to indicate the actual measureable achievement <br /> of goals. If goals were not met, please explain. (i.e_ Delivered an average of 105 meals per <br /> day.) <br /> Work Statement Chart for Program,Parent Aide Program <br /> .1, Program Aetivity..Name . Parent Aide Program: Home Visiting <br /> Program Goal Parents will increase parenting skills and parent/child interaction <br /> and increase problem-solving skills and family functioning. <br /> Performance Measures Protective Factors Survey(Retrospective Post), North Carolina F <br /> Family Assessment Scale(Pre, Mid, Post), Adult Adolescent <br /> Parenting Inventory(Pre/Post), Safe Care Assessments. <br /> Previous Year Program Results 93% <br /> Current Year Estimated Results 96% <br /> Next Year Projected Results 95% <br /> 2 Program Activity.Name _ Parent Aide Program: Home Visiting i <br /> Program Goal Parents enhance home safety, increase linkages to <br /> social/community supports, and improve their capacity to maintain <br /> their child's health. F <br /> Performance Measures Protective Factors Survey(Retrospective Post), North Carolina <br /> Family Assessment Scale(Pre, Mid, Post), Adult Adolescent F <br /> Parenting Inventory(Pre/Post), Safe Care Assessments. <br /> Previous Year Program Results 93% <br /> Current Year Estimated Results 96% <br /> Next Year Projected Results 95% <br /> • 3:'-:'Program:Actiuity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> 4.. Program Activity.Name <br /> Program Goal <br /> PROGRAM INFORMATION 1/27/2017 1:48.20 PM Page 1 1 of 1 2 <br />