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DocuSign Envelope ID:42FC26E4-086D-47F4-A291-0A9A8706CA60 <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 ECH Community Support and Engagement Services <br /> 1. Program Activity Name Information, Referral, and Support Services <br /> Program Goal 1,200 referrals and support services rendered to Latinos and other <br /> community members in the Orange County, Chapel Hill, and <br /> Carrboro areas <br /> Performance Measures #of referrals and support services provided; #of new users <br /> Previous Year Program Results 1403 services provided; 889 new users <br /> Current Year Estimated Results 1,000 Goal for year; 661 people served as of 12/31/16 <br /> Next Year Projected Results I At least 1,200 <br /> 2. program Activity Name Legal Assistance <br /> Program Goal 150 appointments made for individuals in need of legal services <br /> Performance Measures #of appointments made; #of appointments kept <br /> Previous Year Program Results 153 appts made; 93 appts kept <br /> Current Year Estimated Results 100 Goal for year; 90 appts made as of 12/31/16; <br /> Next Year Projected Results At least 150 <br /> 3. Program Activity Name Community Education and Outreach <br /> Program Goal 7 Community Events will be held (such as the Forums, Faith ID <br /> Drives & the Latin-American Festival) to improve communication, <br /> engagement, and access to area resources by Latino community <br /> members as well as to foster cross-cultural appreciation and <br /> understandin. <br /> Performance Measures #of events held;#of participants <br /> Previous Year Program Results n/a <br /> Current Year Estimated Results 2 Community-Law Enforcement Forums; 4 Faith ID Drives; 1 Latin- <br /> American Festival <br /> Next Year Projected Results At least 7 community events <br /> PROGRAM INFORMATION 1/31/2017 3:16:25 PM Page 15 of 32 <br />