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DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 306 *does not 343 *does <br /> equal 364 not equal 375 <br /> 246 *does not because we because we <br /> equal 292 estimate we estimate we <br /> because we will serve will serve <br /> had 46 clients approximately approximately <br /> 58 clients from 32 clients <br /> from other NC other NC from other <br /> counties or out counties or out NC counties <br /> Total of state of state or out of state <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 Residential Services <br /> 1. Program Activity Name Residential Services <br /> Program Goal Community House and HomeStart will provide safe, <br /> emergency shelter and transitional housing, as well as Case <br /> Management to reduce obstacles to overcoming <br /> homelessness <br /> Performance Measures Information logged into the HMIS and an in-house data <br /> collection system <br /> Previous Year Program Results 292 homeless persons received shelter <br /> Current Year Estimated 364 homeless persons receive shelter, with access to Full- <br /> Results Time Case Managers <br /> Next Year Projected Results 375 homeless persons receive shelter, with access to Full- <br /> Time Case Managers <br /> 2. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated <br /> Results <br /> Next Year Projected Results <br /> PROGRAM INFORMATION 1/31/2017 11.43.55 AM P go 'Inn of 3 5 <br />