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DocuSign Envelope ID: 1327919D -9891- 4603- B056- 5CA1EBBFDF23 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Work Statement <br />a) Complete the Work Statement Chart to describe the work to be performed. <br />This chart is used to document program activities, program goals, performance <br />measures, and actual results. (Add more rows as needed) If this is a new <br />program, you will only document the projected information. Every program is <br />required to have AT LEAST 1 Program Activity, which should be SMART <br />(Specific, Measurable, Achievable, Relevant, and _Time- bound. Click on SMART <br />Goals to learn more. <br />• Program Activities should outline major activities the agency implements to <br />accomplish its program goals. (i.e. Deliver meals to elderly /disabled residents.) <br />• Program Goal should explain what the program is trying to achieve /accomplish. <br />Goals are statements about what the program should accomplish. (i.e. Deliver <br />100 meals per day, Monday- Friday.) <br />• Performance Measures describe how you will evaluate the degree in which you <br />achieved the stated goals. (i.e. Will track the number of meals delivered each <br />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 <br />average of 105 meals per day.) <br />Work Statement Chart for Program- Voices Together <br />1. Program Activity Name <br />Specialized music -based therapy program that teaches <br />communication and social /emotional skill building <br />Program Goal <br />Communicates thoughts and emotions <br />Performance Measures <br />Increase in language and vocalization (70 -80 students) <br />Previous Year Program <br />+41% <br />Results <br />Current Year Estimated <br />+30% <br />Results <br />Next Year Projected Results <br />+25% <br />2. Program Activity Name <br />Specialized music -based therapy program that teaches <br />communication and social /emotional skill building <br />Program Goal <br />Increase social communication <br />Performance Measures <br />Percentage of students able to acknowledge others by using <br />appropriate communication skills (70 -80 students) <br />Previous Year Program <br />+50% <br />