Orange County NC Website
Browse       Search
DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Age <br />Of the above, how many Hispanic /Latino <br />Of the above, how many non-Hispanic/Latino <br />Total <br />0 -5 years <br />6 -18 years <br />19 -50 years <br />51+ years <br />_. .... Total <br />Geographic Location <br />Alamance County <br />Chatham County <br />Durham County <br />Wake County <br />Orange County Breakdown <br />Chapel Hill Public Housing <br />Town of Chapel Hill (Non - Public Housing) <br />Town of Carrboro <br />Town of Hillsborough. <br />City of Mebane (Orange County) <br />Orange County (Outside Municipalities) <br />Work Statement <br />7 <br />14 <br />21 <br />119 <br />136 <br />154 <br />126 <br />156 <br />175 <br />5 <br />8 <br />12 <br />75 <br />85 <br />95 <br />31 <br />40 <br />50 <br />20 <br />25 <br />30 <br />126 <br />150= <br />175 <br />5 <br />8 <br />12 <br />2 <br />10 <br />15 <br />15 <br />20 <br />25 <br />68 <br />70 <br />80 <br />Total 1 100 1 114 1 167 <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 document <br />the projected information. Every program is required to have AT LEAST 1 Program Activity, <br />which should be SMART (Specific, Measurable, Achievable, Relevant and _Time-bound. Click <br />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 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 measurable achievement <br />of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per <br />day.) <br />Agency Information 1/22/2018 10:12:15 AM P a g e 1 6 o f 3 0 <br />3 <br />3 <br />6 <br />1 <br />2 <br />3 <br />2 <br />5 <br />6 <br />7 <br />14 <br />20 <br />Total 1 100 1 114 1 167 <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 document <br />the projected information. Every program is required to have AT LEAST 1 Program Activity, <br />which should be SMART (Specific, Measurable, Achievable, Relevant and _Time-bound. Click <br />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 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 measurable achievement <br />of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per <br />day.) <br />Agency Information 1/22/2018 10:12:15 AM P a g e 1 6 o f 3 0 <br />