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DocuSign Envelope ID: 7A9252AF- OE3A- 47EE- A4F6- 2A3D9DF527FF <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, <br />and 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 _Promise of Home: _ <br />1. Program Activity Name <br />Keeping Your House a Home Preservation workshops and wills <br />drafting clinics <br />Program Goal <br />Ensure that 75 elderly, low- income residents receive home <br />preservation education and equitable access to legal and financial <br />services and end -of -life documents. <br />Performance Measures <br />Track numbers of household participants in workshops and legal <br />clinics, as well as those connected to legal and financial services; <br />evaluations for all households. <br />Previous Year Program Results <br />36 elderly and/or low income residents completed workshops <br />and/or connected to services <br />Current Year Estimated Results <br />50 elderly and/or low income residents completed workshops <br />and /or connected to services <br />Next Year Projected Results <br />75 elderly and /or low income residents completed workshops <br />and/or connected to services <br />2. Program Activity Name <br />Home Repair Advocacy <br />Program Goal <br />Ensure at least 15 households, primarily in Tin Top, Pine Knolls, <br />and Lloyd /Broad receive coordinated, comprehensive, quality home <br />repairs; ensure that an additional 20 families across the County <br />receive advocacy and referral support. <br />Performance Measures <br />Track # of households; home repair evaluation monitors quality and <br />timeliness <br />Previous Year Program Results <br />12 coordinated repairs, primarily in Northside; 12 additional <br />advocac clients receive repairs through partner referrals <br />Current Year Estimated Results <br />14 coordinated repairs, primarily in Northside; 12 additional <br />advocacy clients receive repairs through partner referrals <br />Next Year Projected Results <br />15 coordinated repairs, spread across 4 neighborhoods; 20 <br />additional advocacv clients receive repairs through partner referrals <br />3. Program Activity Name <br />Emergency Repair Program <br />Program Goal <br />Coordinate at least 12 urgent repairs within 1 week turnaround; add <br />at least three vendors to existing repair vendor list. <br />PROGRAM INFORMATION 1/23/2018 2:58:40 PM Page 7 of 10 <br />