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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(S_fiecific, 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 Education Services <br /> 1, Program Activity Name School Readiness- Preschool Classroom <br /> Program Goal 30 children 0-5 will participate in the pre-school classroom <br /> Performance Measures #of children participating <br /> Previous Year Program Results 62 children participated <br /> Current Year Estimated Results 25 Goal; 27 have participated as of 12/31/2016 <br /> Next Year Projected Results At least 30 children <br /> 2. Program Activity Name School Achievement- K-8 Tutoring <br /> Program Goal 30 children in K-8 will receive tutoring for homework (4hrs per <br /> week <br /> Performance Measures #of children participating <br /> Previous Year Program Results 37 children participated <br /> current Year Estimated Results 25 Goal; 24 children have been tutored since 12/31/2917 <br /> Next Year Projected Results At least 30 children <br /> 3. Program Activity Name Circle of Parents <br /> Program Goal 30 parents/caretakers of children 0-5 will participate in Circle of <br /> Parent sessions <br /> Performance Measures #of parents attending; #of parents that complete the program <br /> Previous Year Program Results 38 parents attended <br /> Current Year Estimated Results 14 parents have attended as of 12/31/16 <br /> Next Year Projected Results At least 30 parents <br /> 4. Program Activity Name Adult Literacy- ESL <br /> Program Goal 100 will participate in literacy and/or ESL classes <br /> Performance Measures #of participants in classes <br /> Previous Year Program Results 38 individuals attended <br /> Current Year Estimated Results 100 Goal; 24 attended as of 12/31/16 <br /> Next Year Projected Results At least 100 <br /> PROGRAM INFORMATION 1/31/2017 3;16:25 PM Page 31 of 32 <br />