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DocuSign Envelope ID:0E0892A5-AB8C-4E61-8B53-2125B8922B1C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Town of Carrboro 26 11 <br /> Town of Hillsborough 15 2 100 <br /> City of Mebane (Orange County) <br /> Orange County(Outside Municipalities) 498 <br /> Total 1,386 I 866 1,199 <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 _Kidzu Children's Museum "Community Connections" <br /> 1. Program Activity Name STEM "museum in a box" activities <br /> Program Goal Provide monthly, hour long STEM activities to youth aged 1- <br /> 12 in three sites (Cedar Grove Community Ctr SUMMER <br /> ONLY, New Hope Elementary, Fair View Child and Family <br /> Ctr). Serve upwards of 150 children between three sites. <br /> Promote STEM education and design thinking process. <br /> Performance Measures Program attendance, tracking ages, ethnicity and residence; <br /> formative and summative quantitative survey data measuring <br /> understanding and educational value of key STEM learning <br /> concepts. Serve 65 children at Cedar Grove, 50 children at <br /> New Hope Elementary and 25 children at Fairview Child and <br /> Family Ctr. <br /> Previous Year Program In 2016 Kidzu worked with an average of 15 children per site <br /> Results (in a similar program in the S. Estes community in Chapel <br /> Hill, for example, and 60 children at Hargraves Community <br /> Center) <br /> PROGRAM INFORMATION 2/9/2017 1.27.17 PM Pago 23 of 30 <br />