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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> 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 Program <br /> Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- <br /> 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 EarthKeepers Afterschool Program <br /> 1. Program Activity Name Perform 1 two-hour continuing education credit for <br /> teachers <br /> Program Goal Teachers get trained on nature mentoring and <br /> continuing ed credit <br /> Performance Measures Training approved by Community Schools Director, <br /> teacher participant sign in sheet used <br /> Previous Year Program Results Mary Roberts approved continuing ed; 10 teachers <br /> attended <br /> Current Year Estimated Results not applicable (N/A) <br /> Next Year Projected Results Community Schools Director approves continuing ed <br /> credit, 4 teachers attend <br /> 2. Program Activity Name Afterschool Teachers will be able to facilitate program <br /> activities <br /> Program Goal Afterschool teachers will be able to incorporate their <br /> teacher training and assist or lead activities <br /> Performance Measures PWC staff will observe teachers facilitating activities <br /> with the students <br /> Previous Year Program Results 100% of the teachers helped facilitate the activities <br /> Current Year Estimated Results N/A <br /> Next Year Projected Results 90% of the teachers will help facilitate the activities <br /> 3. Program Activity Name 2-hour programs are taught during three 7 week <br /> sessions in the 2017-18 school year to an average of <br /> 195 afterschool students <br /> Program Goal Teach 8 weeks in the fall, 2 - 6 week sessions in the <br /> 1/12/2017 2:56:42 PM II I:' 16 lr 29 <br />