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DocuSign Envelope ID: A0992361- 7662- 4FD7- 9DB3- 9D760E06A5D2 <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, and actual <br />results. (Add more rows as needed) If this is a new program, you will only document the projected <br />information. Every program is required to have AT LEAST 1 Program Activity, which should be <br />SMART (Specific, Measurable, Achievable, _Relevant, and _Time-bound. Click on SMART Goals to <br />learn more. <br />• Program Activities should outline major activities the agency implements to accomplish its program <br />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, Monday - <br />Friday.) <br />• Performance Measures describe how you will evaluate the degree in which you achieved the stated <br />goals. (i.e. Will track the number of meals delivered each day.) <br />• Actual Program Results use program results to indicate the actual measureable achievement of <br />goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) <br />Work Statement Chart for Program Transitions to Employment <br />1. Program Activity Name <br />Student Participant Employment <br />Program Goal <br />15 student participants will obtain jobs in the community or <br />increase their marketability through post- secondary education <br />Performance Measures <br />Student participants obtaining jobs in the community or <br />increasing their marketability through post- secondary <br />education. <br />Previous Year Program Results <br />5 (Obtaining jobs in the community) <br />Current Year Estimated Results <br />15 <br />Next Year Projected Results <br />25 student participants will obtain jobs in the community or <br />increase their marketability through community based <br />vocational opportunities. <br />2. Program Activity Name <br />Adult Participant Employment <br />Program Goal <br />50 adult participants will obtain jobs in the community <br />Performance Measures <br />Number of adults placed in competitive employment <br />Previous Year Program Results <br />41 <br />Current Year Estimated Results <br />50 <br />Next Year Projected Results <br />3. Program Activity Name <br />50 adult participants will obtain jobs in the community <br />Senior Engagement <br />Program Goal <br />10 senior adult participants (age 55 +) will participate in <br />Community Senior and retirement activities <br />Performance Measures <br />Measuring meaningful senior activities and retirement <br />participation of disabled elderly program participants <br />Previous Year Program Results <br />10 <br />Current Year Estimated Results <br />11 <br />Next Year Projected Results <br />10 senior adult participants (age 55 +) will participate in <br />Community Senior and retirement activities <br />PROGRAM INFORMATION 1/22/2018 1:53:42 PM P a g � 1 6 s t 11 <br />