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DocuSign Envelope ID:60192208-BFA3-4E38-9277-B2390FDDC97D <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, Re levant, 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: _Behavioral Insights: Programming to Fulfill Court and <br /> CPS Mandates_ <br /> 1.. Program Activity Name Assess referred participants to determine suitability for BI's <br /> interventions (Assessment to include lethality screening) <br /> Program Goal Conduct assessment of 80% of referred participants <br /> Performance Measures Will maintain database of referred participants <br /> Previous Year Program Results N/A <br /> Current Year Estimated Results Will conduct assessment of 7 participants <br /> Next Year Projected Results Will conduct assessment of 122 participants <br /> 2. Program Activity Name , Provide referrals to address barriers to participant success <br /> Program Goal Provide referrals to 90% of participants assessed <br /> Performance Measures Will maintain database of referrals made to assessed participants <br /> Previous Year Program Results N/A <br /> Current Year Estimated Results Will provide referrals to 5 participants <br /> Next Year Projected Results Will provide referrals to 110 participants <br /> 3. Program Activity Name. Provide Anger Management, Batterer Intervention, and Strong <br /> Fathers interventions <br /> Program Goal 80% of enrolled participants will complete assigned program <br /> Performance Measures Will maintain records of attendance and program completion <br /> Previous Year Program Results N/A <br /> Current Year Estimated Results 7 participants will complete Batterer Intervention or Anger <br /> Management <br /> Next Year Projected Results 98 participants will complete Anger Management, Batterer <br /> Intervention, or Stron• Fathers <br /> 4. Program Activity Name Interface with local domestic violence, child protection, and criminal <br /> justice personnel and organizations <br /> Program Goal Conduct/attend at least 3 meetings or presentations/month for/with <br /> local domestic violence, child protection, or criminal justice <br /> PROGRAM INFORMATION 1/30/2017 10:59:56 AM Page 17 of 21 <br />