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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Wake County 7 7 7 <br /> Orange County Breakdown <br /> Chapel Hill Public Housing <br /> Town of Chapel Hill (Non-Public Housing) 1 1 <br /> Town of Carrboro 1 2 <br /> Town of Hillsborough 1 1 1 <br /> City of Mebane (Orange County) <br /> Orange County(Outside Municipalities) 1 <br /> Other 8 8 8 <br /> Total 22 24 26 <br /> Work Statement <br /> b) 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 document <br /> the projected information. Every program is required to have AT LEAST 1 Program Activity, <br /> which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click <br /> 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 Wheelchair Basketball <br /> 5. Program Activity Name Wheelchair Basketball Practices <br /> Program Goal Practices develop sport skills, communication, teamwork, <br /> independence and physical activity for cross disabilities. <br /> Performance Measures Weekly: Coaching plans executed; reflection/assessment of <br /> practices; 4 individual goals tracked. <br /> Previous Year Program Results Held 24 practices in 2017; served 22 athletes &20 college students; <br /> Raised awareness to audience size of 1,600. <br /> Current Year Estimated Results Hold 24 practices in 2017; serve 24 athletes & 25 college students; <br /> Raise awareness to audience size of 2,000. <br /> Next Year Projected Results Hold 24 practices in 2018; serve 26 athletes & 30 college students; <br /> Raise awareness to audience size of 2,200. <br /> 6. Program Activity Name Wheelchair Basketball Tournaments <br /> Program Goal Tournaments are organized to apply sport skills, leadership, <br /> sportsmanship, and confidence in competition. <br /> Performance Measures East Coast team registration allows for social networking and <br /> physical competition of peers with similar disabilities. <br /> PROGRAM INFORMATION 1/27/2017 3:48:29 PM Pago 22 of 2 6 <br />