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DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 <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, <br /> and actual results. (Add more rows as needed) If this is a new program, you will only <br /> document the projected information. Every program is required to have AT LEAST 1 <br /> Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and <br /> Time-bound. Click on SMART Goals to learn 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 <br /> the stated goals. (i.e. Will track the number of meals delivered each day.) <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program Youth Afterschool Tutoring <br /> 1. Program Activity Name Provide afterschool tutoring to low-income, at-risk students <br /> Program Goal At least 85 children will be served over the course of the school <br /> year <br /> Performance Measures We will track the number of students served <br /> Previous Year Program Results At least 50 children served <br /> Current Year Estimated Results At least 66 children served <br /> Next Year Projected Results At least 85 children served <br /> 2. Program Activity Name Increase proficiency of low performing students <br /> Program Goal At least 75% of students in the program will be proficient in reading <br /> and/or math by the end of the program. <br /> Performance Measures Standardized tests <br /> Previous Year Program Results Not available <br /> Current Year Estimated Results At least 75% of students in the program will be proficient in reading <br /> and/or math by the end of the program. <br /> Next Year Projected Results At least 75% of students in the program will be proficient in reading <br /> and/or math b the end of the •ro•ram. <br /> 3. Program Activity Name Show growth in subject areas for all students <br /> Program Goal All students will show growth in their math and/or reading abilities <br /> Performance Measures Standardized tests <br /> Previous Year Program Results Not available <br /> Current Year Estimated Results 1 All students will show growth in their math and/or reading abilities <br /> Next Year Projected Results All students will show growth in their math and/or reading abilities <br /> 4. Program Activity Name Increase self-confidence of low-performing students <br /> Program Goal Increase confidence of all students in their reading and/or math <br /> skills <br /> Performance Measures Anecdotal evidence from tutors and teachers <br /> Previous Year Program Results Not Available <br /> PROGRAM INFORMATION 1/27/2017 10:08:56 AM Page 17 of 2 2 <br />