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DocuSign Envelope ID: 4B292955- 9A36- 47C6- BDDE- 4E9CDOBA074D <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 <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 Program Volunteers for Youth <br />1. Program Activity Name <br />Mentoring <br />Program Goal <br />At least 80% of youth will complete their mentoring matches. <br />Performance Measures <br />Track client progress through contact with mentors and clients. <br />Previous Year Program Results <br />38 of 41 youth (92 %) completed their mentoring matches. <br />Current Year Estimated Results <br />40 of 44 youth (90 %) will complete their mentoring matches. <br />Next Year Projected Results <br />51 of 60 youth (85 %) will complete their mentoring matches. <br />2. Program Activity Name <br />Community Service <br />Program Goal <br />At least 80% of youth will have no new charges while in the <br />program. <br />Performance Measures <br />Track client progress through contact with youth, court counselors. <br />Previous Year Program Results <br />54 of 59 youth (92 %) had no new charges while in the program. <br />Current Year Estimated Results <br />54 of 60 youth (90 %) will have no new charges while in the <br />program. <br />Next Year Projected Results <br />53 of 62 youth (85 %) will have no new charges while in the <br />program. <br />3. Program Activity Name <br />Teen Court <br />Program Goal <br />At least 80% of youth will have no new charges while in the <br />program. <br />Performance Measures <br />Track client progress through contact with youth, court counselors. <br />Previous Year Program Results <br />51 of 54 youth (94 %) had no new charges while in the program. <br />Current Year Estimated Results <br />50 of 56 youth (90 %) will have no new charges while in the <br />program. <br />Next Year Projected Results <br />49 of 58 (85 %) of youth will have no new charges while in the <br />program <br />rPeirformance gram Activity Name <br />Program Goal <br />Measures <br />PROGRAM INFORMATION 2/12/2018 10:22:38 AM Page 20 of 25 <br />