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DocuSign Envelope ID:9B26E979-2C09-4BE7-801C-3DDB484D92EE XHIBIT A <br /> PROVIDER"S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> I) 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, Orange County Rural Alliance (OCRA) <br /> a) Program Activity Name Deliver meals to elderly/disabled rural residents <br /> Program Goal Deliver 50 meals, Three times (M,W,F)a week <br /> Performance Measures Will track the number of meals delivered each week <br /> Previous Year Program Results 2 mos in operation (Nov-Dec) one meal reliably delivered each <br /> week to 40 seniors <br /> Current Year Estimated Results 4000 meals delivered July 1, 2017-June 31,2018 for 50 seniors <br /> Next Year Projected Results 7500 meals delivered July 1,2018-June 31, 2019 for 50 seniors <br /> b) Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> c) Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> d) Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> PROGRAM INFORMATION 2/8/2017 4:36:09 PM Page 15 • .f 1 "' ' <br />