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DocuSign Envelope ID:2A83AE93-E43A-4DCA-8002-FA0D789204A6 <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 Community and School-Based Mentorinq <br /> 1. Program Activity Name Match at-risk children, ages six to 14, who reside in Durham, <br /> Wake, or Orange Counties, with professionally screened and <br /> trained adult mentors who will provide a positive role model in <br /> their lives. <br /> Program Goal We are trying to make more matches between Bigs and <br /> Littles. We are also working hard to continue to increase the <br /> length of those matches. <br /> Performance Measures We focus on creating and sustaining long, strong <br /> relationships with measurable impact. Once the match is <br /> made, our program staff members call or meet monthly with <br /> Bigs, Littles, and their parents and track information about <br /> the match in our Agency Information Management (AIM) <br /> system, producing a written record of the relationship. We <br /> also request that parents give us a copy of their child's report <br /> card —this allows us to track grades, attendance, and <br /> classroom behavior. Additionally, we give pre- and post- <br /> surveys to Littles in both of our main programs to help <br /> evaluate the effectiveness of our work with the children. We <br /> enter this information into AIM as well to produce hard data <br /> to demonstrate that our mentoring helps children succeed in <br /> school and in life. <br /> Previous Year Program Results We served 1068 children in our service area. Our Average <br /> Match Length (AML) was 28.5 months for Community-Based <br /> Matches and 21.9 months for School-Based Matches. <br /> Current Year Estimated Results We are serving 1030 children in our service area. Our AML <br /> was 29.8 months for Community-Based Matches and 22.1 <br /> months for School-Based Matches. <br /> PROGRAM INFORMATION 1/27/2017 1 :43:18 PM Page 19 of 24 <br />