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DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Total 81 86 97 1 <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( pecific, Measurable, Achievable, Relevant, and <br /> Time-bound. Click on SMART Goals to learn more. <br /> O 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. (Le. Delivered an average of <br /> 105 meals per day.) <br /> Work Statement Chart for Program: Meals on Wheels <br /> 1. Program Activity Name Deliver meals to elderly/disabled residents. <br /> Program Goal Deliver 45 meals per day(70 people for the year), Monday-Friday. <br /> Performance Measures Will track the number of meals delivered each day. <br /> Previous Year Program Results 81 people received meals in 2016, daily average of 42. <br /> Current Year Estimated Results 86 people will receive meals in 2017, daily average of 43. <br /> Next Year Projected Results 91 people will receive meals in 2018, daily average of 45. <br /> 2. Program Activity Name Increase meal delivery to the Cedar Grove and Little River <br /> township& <br /> Program Goal Deliver meals to an additional six people, distributed from the <br /> Cedar Grove Community Center. <br /> Performance Measures Will track the number of meals delivered each day. <br /> Previous Year Program Results This is a new initiative. <br /> Current Year Estimated Results This is a new initiative. <br /> Next Year Projected Results Six people in the Cedar Grove and Little River townships will <br /> receive Meals on Wheels delivery. <br /> 3. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> 4. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> lA1PriF?AllATInAl 1/q1/21)17 R-1A-t7Q AAA P R n <br />