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DocuSign Envelope ID:6D821DA0-CO6F-4D38-BB4F-DB28CB54AD8E XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 Program <br /> Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- <br /> 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 Transitions to Employment <br /> 1. Program Activity Student Participant Employment <br /> Name <br /> Program Goal 15 student participants will obtain jobs in the community <br /> Performance Measures Number of students placed in competitive employment <br /> Previous Year Program 8 <br /> Results <br /> Current Year Estimated 10 <br /> Results <br /> Next Year Projected 15 student participants will obtain jobs in the community <br /> Results in increase their marketability through post-secondary <br /> education <br /> 2. Program Activity Adult Participant Employment <br /> Name <br /> Program Goal 50 adult participants will obtain jobs in the community <br /> Performance Measures Number of adults placed in competitive employment <br /> Previous Year Program 47 <br /> Results <br /> Current Year Estimated 50 <br /> Results <br /> Next Year Projected 50 adult participants will obtain jobs in the community <br /> Results <br /> 3. Program Activity Senior Engagement <br /> Name <br /> Program Goal 5 senior adult participants (age 55+) will participate in <br /> Community Senior and retirement activities <br /> Performance Measures Measuring meaningful senior activities and retirement <br /> participation of disabled elderly program participants <br /> PROGRAM INFORMATION 1/31/2017 8:24:51 AM P g 1 "' f 20 <br />