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DocuSign Envelope ID: 42882613- 58E8 -4BA1- 9376- A348D7FC56CA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Town of Chapel Hill (Non - Public Housing) <br />Town of Carrboro <br />Town of Hillsborough <br />City of Mebane (Orange County) <br />Orange County (Outside Municipalities) <br />Work Statement <br />Total 1 0 1 453 1 485 <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 Program <br />Activity, which should be SMART (Apecific, Measurable, Achievable, Relevant, and <br />Time - bound. Click on SINART 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 measurable <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 _Chapel Hill Impact Program <br />I. Program Activity Name <br />Homework Assistance and Tutoring <br />Program Goal <br />To ihcrease grades in reading and/or math by 1 point (scale 1-4) for <br />20% of youth members. <br />Performance Measures <br />Report card measurement <br />Previous Year Program Results <br />Met goal <br />Current Year Estimated Results <br />Already exceeded by 20°% over goal <br />Next Year Projected Results <br />Expect to reach or exceed goal. <br />2. Program Activity Name <br />Improve interpersonal and social skills of youth members <br />Program Goal <br />75°% of youth members will meet standards set by school in four <br />categories. <br />Report card indicators: <br />1. Follows classroom rules. <br />2. Takes responsibility <br />for behaviors and actions. <br />3. Respects and cooperates with others, <br />4. Follows directions. <br />