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DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> nn)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 /> 5. Program Activity Name Support Circles <br /> Program Goal Support Circles will function as a support system for a <br /> formerly homeless individual or family transitioning into <br /> permanent housing <br /> Performance Measures Number of new and active Circles <br /> Previous Year Program Results 3 new, 8 active over the course of the year <br /> Current Year Estimated Results 5 new, 6 active <br /> Next Year Projected Results 5 new, 6 active <br /> 6. 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 /> 7. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> oo)Program Budget <br /> 9. Submit your program budget. You may complete the provided template (separate xls <br /> file) or you may submit your own budget file (as long as it contains the same information, <br /> in the same format, as requested in the provided template). <br /> Program Budgets are required to define budget amounts for the previous program <br /> year, current program year, and next program year for the following categories: <br /> PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 32 of 35 <br />