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DocuSign Envelope ID: DB2FC63F- 0403 - 4403- BF86- OF5CB206F3F3 <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 Program <br />Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and _Time- <br />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 Orange County Rural Alliance (OCRA) <br />1. Program Activity Name <br />Meal delivery to elderly /disabled rural residents <br />Program Goal <br />Deliver 120 meals, two times a week <br />Performance Measures <br />Will track the number of meals delivered each week <br />Previous Year Program Results <br />Delivered meals to 82 seniors /disabled once a week <br />Current Year Estimated Results <br />4000 meals delivered from Jan 1 -Dec 31, 2017 <br />Next Year Projected Results <br />Deliver 12,480 meals to 120 seniors /disabled twice a week <br />2. 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 />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 Activity Name <br />Program Goal <br />Performance Measures <br />Previous Year Program Results <br />Current Year Estimated Results <br />Next Year Projected Results <br />DO NOT SUBMIT THIS PAGE 1/12/2018 10:05:28 AM Page 2 1 of 25 <br />