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DocuSign Envelope ID: D068E7B0- D869- 43F4- B35C- 428F10E3BDC1 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Work Statement <br />o) 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 MEDIATION <br />I. Program Activity Name. <br />Court Mediation <br />Program Goal <br />Offer mediation in Orange County Criminal District Court <br />Performance Measures <br />Numbers of people assisted with conflict and resolution rate for <br />cases mediated. <br />Previous Year Program Results <br />247 assisted with an 82 % resolution rate for cases mediated. <br />Current Year Estimated Results <br />250 assisted with an 80% resolution rate for cases mediated <br />Next Year Projected Results <br />250 people with 80% resolution rate for cases mediated <br />2. Program Activity Name.. <br />Community mediation <br />Program Goal <br />Assist people with family, neighborhood, business, Medicaid <br />services and other conflicts <br />Performance Measures <br />Numbers of people assisted and resolution rate of cases mediated <br />Previous Year Program Results <br />359 people assisted; resolution rate 78% <br />Current Year Estimated Results <br />390 people assisted; resolution rate 80% <br />Next Year Projected Results <br />400 people assisted; resolution rate 80% <br />3. 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 />4; Program Actiivity'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 2/28/2018 12.51:40 PM Page 2 2 of 27 <br />