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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> City of Mebane(Orange County) 32 1 35 35 <br /> Orange County(Outside Municipalities) 35 38 38 <br /> Unknown 463 634 634 <br /> Total 1324 1330 j 1330 <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: Domestic Violence Crisis Services <br /> .......- _. „ _- Name '.1. Program Activity Crisis Intervention: <br /> Provide direct services to victims of <br /> domestic violence including crisis intervention, support <br /> groups and advocacy in order to reduce trauma and increase <br /> clients' ability to make choices increasing their safety and <br /> that of their children <br /> Program Goal 85% of clients who meet with crisis response staff will <br /> develop a safety plan that meets their needs and helps them <br /> feel that they have options to improve their safety. At least <br /> 1,000 clients will be served in FY 17-18. <br /> Performance Measures All clients who meet in person with crisis response staff or <br /> attend support group are asked to fill out a survey and <br /> responses are tracked. <br /> Previous Year Program Results FY Y 15-16: 97% <br /> Current Year Estimated Results FY 16-17 Goal: 85% Estimated Result: 97% <br /> Next Year Projected 17-18 Goal: <br /> d Results FY 17-1 I: 85% Procected Result: 97% <br /> 2. Program Activity Name ' Court Advocacy: Provide court services to victims of 1 <br /> domestic violence to reduce the trauma and confusion that <br /> xe court process. <br /> clients experience in the <br /> �..�........ ....�. . �Program Goal ..... ..... . process. <br /> of clients will report feeling supported by court <br /> advocates in FY 17-18. At least 150 clients will be served. <br /> Performance Measures All clients receiving court advocacy will be asked to fill out a <br /> survey and responses are tracked. <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM I ' ,u (_1 8 0 o 1 4 8 <br />