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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Total 1 500 500 700 <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 <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 <br />1. Program Activity Name <br />Disaster Preparedness <br />Program Goal <br />To educate about the risks of personal surroundings, reduce risk <br />Performance Measures <br />Written statements about actions to be taken <br />Previous Year Program Results <br />10 attendees <br />Current Year Estimated Results <br />19 attendees <br />Next Year Projected Results <br />25 attendees <br />2. Program Activity Name <br />Affordable Housing <br />Program Goal <br />Provide ADA- compliant fair housing info to landlords and tenants <br />Performance Measures <br />Quizzes, self- assessment tools, and follow -up email <br />Previous Year Program Results <br />17 <br />Current Year Estimated Results <br />28 <br />Next Year Projected Results <br />40 <br />3. Program Activity Name <br />Technology Literacy Classes for the Blind <br />Program Goal <br />Provide assistive technologies to aid in job placement <br />Performance Measures <br />Questionnaires that will be graded and course evaluations <br />Previous Year Program Results <br />12 <br />Current Year Estimated Results <br />15 <br />Next Year Projected Results <br />22 <br />4. Program Activity Name <br />ADA Selected Topic Training Workshops <br />Program Goal <br />Improve access to public accommodations for the disabled <br />Performance Measures <br />Written statements, surveys, evaluations <br />Previous Year Program Results <br />20 <br />PROGRAM INFORMATION 2/9/2017 4:31:06 PM P a g e 18 of 2 2 <br />