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DocuSign Envelope ID: El 573D55-1 DC0 -4F4C- 9784- 749E3E95640B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Apartments and several section 8 residents but numbers <br />are approximate <br />Total 290 320 370 <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 Proaram: Meal Delivery <br />1. Program Activity Name <br />Deliver hot ready to eat meals and extras each weekday <br />Program Goal <br />Provide hot, nutritious and a friendly check -in with every client <br />Performance Measures <br />Volunteer log, client delivery records, & annual survey <br />Previous Year Program Results <br />46,000 meals delivered plus additional groceries and food <br />donations <br />Current Year Estimated Results <br />47,030 meals delivered plus additional groceries and food <br />donations <br />Next Year Projected Results <br />48,500 meals delivered plus additional groceries and food <br />donations <br />2. Program Activity Name <br />Friendly Visit /Check -In with Client <br />Program Goal <br />Provide a personal visit each weekday, relieving isolation and <br />depression. Check -in on client's health and general well- being. <br />Quick review of home situation and noting of any problems that <br />need attention from family or other service providers. The latter are <br />reported back to Operations Manager and handled with the client, <br />their emergency contact or through referral to other agencies. <br />Performance Measures <br />Notes in client files and incident reports submitted by volunteers <br />We deliver every weekday, excluding only 5 -6 major holidays and <br />there are often two volunteers that deliver on each route, When you <br />aggregate those interactions you get the numbers below which are <br />estimates. <br />Previous Year Program Results <br />110 volunteers, 170 clients daily average (290 clients in a year) if <br />everyone answers the door it is approximately 45,000 touch points <br />Current Year Estimated Results <br />250 volunteers, 178 clients daily average (320 clients per year), if <br />everyone answers the door it is approximately 46,030 touch points <br />Next Year Projected Results <br />265 volunteers, 185 clients daily average (370 clients per year), if <br />everyone answers the door it's approximately 47,500 touch points <br />PROGRAM INFORMATION 1/22/2018 9:22:00 AM Page 21 of 26 <br />