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DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <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 7 <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 700 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 />705 meals per day.) <br />Work Statement Chart for program Anger Management <br />5. 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 />6. 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 />7. 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 />Conduct outreach to acquire referrals from community partners <br />Will receive at least 57 referrals for Anger Management <br />Will track number of referrals received from community partners <br />4 <br />26 <br />57 referrals <br />Conduct assessment on referred individuals <br />Will conduct at least 52 assessments of referred individuals <br />Will track number of assessments completed <br />4 <br />22 <br />46 <br />Enroll assessed participants in program <br />Will enroll at least 37 participants (enrollment aattends 1 session <br />Will track number of participants enrolled <br />4 <br />18 <br />37 <br />8. Program Activity Name See participants through completion of program (10 weeks) <br />Program Goal At least 30 participants will complete 10 -week program <br />Performance Measures Will track number of participants finishing program (10 weeks) <br />Previous Year Program Results 3 <br />Current Year Estimated Results 15 (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 3(l <br />PROGRAM INFORMATION 1/23/2018 11:18.32 AM Page 26 of 30 <br />