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DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D <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 document <br />the projected information. Every program is required to have AT LEAST 1 Program Activity, <br />which should be SMART (Specific, Measurable, Achievable, Relevant, and _Time-bound. Click <br />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 KidSCope <br />1. Program Activity Name <br />Assessment <br />Program Goal <br />Assess 110 children birth to 5 to determine needs <br />Performance Measures <br />100 children will be assessed <br />Previous Year Program Results <br />74 children were assessed <br />Current Year Estimated Results <br />100 will be assessed <br />Next Year Projected Results <br />Provide to 110 children <br />2. Program Activity Name <br />Provide Evidence Based therapeutic interventions to improve <br />behaviors <br />Program Goal <br />Provide to 100 children and family members <br />Performance Measures <br />Provide to 94 children and family members <br />Previous Year Program Results <br />Provided to 74 children and their families <br />Current Year Estimated Results <br />Provide to 100 children and families <br />Next Year Projected Results <br />Provide to 100 children and their families <br />3. Program Activity Name <br />Provide counseling /education to families to increase knowledge of <br />successful parenting and promote positive relationships <br />Program Goal <br />110 children and their family members <br />Performance Measures <br />Provide to 100 children and their family members <br />Previous Year Program Results <br />Provided to 74 children and their family members <br />Current Year Estimated Results <br />Provide to 100 children and their family members <br />Next Year Projected Results <br />Provide to 110 children and their family members <br />4. 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 />PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 22 of 27 <br />