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DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Work Statement <br />oy 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 9 <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 elderlyldisabled 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 900 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 />905 meals per day.) <br />Work Statement Chart for Program Partner Abuse Intervention <br />9. Program Activity Name <br />Program Goal <br />Performance Measures <br />Previous Year Program Results <br />Current Year Estimated Results <br />Conduct outreach to acquire referrals from community partners <br />Will receive at least 65 referrals for Partner Abuse Intervention <br />Will track number of referrals received from community partners <br />4 (Program only available for 2 mos. of previous year) <br />60 <br />Next Year Projected Results <br />65 referrals <br />2. Program_ Activity Name <br />Conduct assessment on referred individuals <br />Program Goal <br />Will conduct at least 52 assessments of referred individuals <br />Performance Measures <br />Will track number of assessments completed <br />Previous Year Program Results <br />3 (Program only available for 2 mos. of previous year) <br />Current Year Estimated Results <br />44 <br />Next Year Projected Results <br />52 <br />3. Program Activity Name <br />'Enroll assessed participants in program <br />Program Goal <br />Will enroll at least 48 participants (enrollment = attends 1 session) <br />Performance Measures <br />Will track number of participants enrolled <br />Previous Year Program Results <br />3 (Program only available for 2 mos, of previous year) <br />Current Year Estimated Results <br />40 <br />Next Year Projected Results <br />48 <br />4. Program Activity Name <br />See participants through completion of program (26 weeks) <br />Program Goal <br />At least 44 participants will complete 26 -week program <br />Performance Measures <br />Will track number of participants finishing program (26 weeks) <br />Previous Year Program Results <br />N/A (Program only available for 2 mos. of previous year — not long <br />enough for any participant to finish <br />Current Year Estimated Results <br />17 (not all participants who enroll this year will be able to finish in <br />this calendar year since program takes 26 weeks to complete) <br />Next Year Projected Results 1 <br />44 <br />PROGRAM INFORMATION 1/2312018 11:18:32 AM Page 19 of 30 <br />