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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Total 4620 4620 4620 <br /> .......... <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: Community Education and Civic Engagement <br /> 6. Program Activity Name and Referral Service: Connects community <br /> members with local resources and services after assessment <br /> of need. Resource database maintained for a multitude of <br /> services. Follow-up conducted to ensure connection was <br /> made and additional resources provided as needed. <br /> �� � .._..... Mm <br /> Program Goal 85/o of clients lients will report they received the -...m.r <br /> information or <br /> help they requested in FY 17-18. At least 70 clients will be <br /> served. <br /> Performance Measures At the end of the contact, all clients are asked whether they <br /> received the information or help they needed. These results <br /> are tracked. <br /> Previous Year Program Results FY 15-16 Results: <br /> Current Year 80%,Estimated Results FY 16-17 Goal: 80% Estimated Result: <br /> 94% <br /> Next Year Projected Results FY 17-18 Goal: <br /> Projected I: 80%, Pro; cted Result: 95% <br /> 7. Program Activity Name Youth Interpersonal Violence Prevention Education <br /> Programs: Provide age appropriate dating violence <br /> prevention education sessions in 6th and 8th grade health <br /> education classes. <br /> Program Goal Out of 1200 participants, 75% will report an increased <br /> awareness of domestic violence and resources available to <br /> victims in FY 17-18. <br /> Performance Measures Participants will be <br /> Ivan pre-and-post-test s ur _. ....._.. <br /> g �w. . surveys and <br /> results will be tracked. <br /> PROGRAM INFORMATION 1/30/2017 4:02:21 PM 1) ago 42 o If 4 8 <br />