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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> • Complete the Work Statement Chart to describe the work to be performed. <br /> This chart is used to document program activities, program goals, performance <br /> measures, and actual results. (Add more rows as needed) If this is a new program, <br /> you will only document the projected information. Every program is required to have <br /> AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, <br /> Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. <br /> • Program Activities should outline major activities the agency implements to <br /> accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) <br /> • Program Goal should explain what the program is trying to achieve/accomplish. <br /> Goals are statements about what the program should accomplish. (i.e. Deliver 100 <br /> meals per day, Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you <br /> achieved 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 <br /> average of 105 meals per day.) <br /> PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 19 90 f 8, <br />