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DocuSign Envelope ID:39EEFC69-D47C-4CE3-8A5C-0A87B55C2CD0 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Work Statement <br /> b) 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: KidSCope Outreach <br /> 1. Program Activity Name Assess children 0-5 to determine needs <br /> Program Goal Assess 122 children in Orange County <br /> Performance Measures 91 children will be assessed <br /> Previous Year Program Results 57 children were assessed <br /> Current Year Estimated Results 90 children will be assessed <br /> Next Year Projected Results 100 children will be assessed <br /> 2. Program Activity Name Provide Evidence Based therapeutic interventions to improve <br /> behaviors <br /> Program Goal Provide to 100 children and family members <br /> Performance Measures Provide to 91 children and families <br /> Previous Year Program Results Provided to 57 children and families <br /> Current Year Estimated Results Provide to 90 children <br /> Next Year Projected Results Provide to 100 children children <br /> 3. Program Activity Name Provide Individual counseling and education to families to increase <br /> knowledge of successful parenting <br /> Program Goal Provide to 100 children and the family members <br /> Performance Measures Provide to 90 children and their family members <br /> Previous Year Program Results Provided to 57 children and their family members <br /> Current Year Estimated Results Provide to 90 and their family members <br /> Next Year Projected Results Provide to 100 children and their family members <br /> 4. 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 /> PROGRAM INFORMATION 2/9/2017 11:59:17 AM 0 ' ago °16 00 °"1 / <br />