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DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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 I <br /> Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and <br /> Time-bound. Click on 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 Young Warriors Program <br /> 1. Program Activity Name 2-5 classes per week for ten weeks. <br /> Program Goal 90% Participants will have no new complaints during program <br /> participation. <br /> Performance Measures See following page <br /> Previous Year Program Results '100% <br /> C urrent Year Estimated Results 100%YTD <br /> Next Year Projected Results 100% <br /> 2. Program Activity Name 2-5 classes per week for ten weeks. <br /> Program Goal 90%of children admitted will participate in a promotion test at the end of <br /> their term(s) and will receive the validation of new belt color/promotion. <br /> Performance Measures See following page <br /> Previous Year Program Results 92% <br /> Current Year Estimated Results 100% YTD <br /> Next Year Projected Results 95% <br /> 3. Program Activity Name 2-5 classes per week for ten weeks. <br /> Program Goal 90%Participants completing the program will demonstrate a reduction in <br /> problem behaviors for which they were referred by termination. <br /> Performance Measures See following page <br /> Previous Year Program Results 84.62% (this period goals were 80% <br /> Current Year Estimated Results 100% YTD <br /> Next Year Projected Results 90% <br /> 4. Program Activity Name 2-5 classes per week for ten weeks. <br /> Program Goal 90% Participants completing the program will demonstrate improvement <br /> in targeted skills as specified in the individual service plan by termination. <br /> PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 14 of 20 <br />