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DocuSign Envelope ID: E30588DE -A1 BC- 443D- A5C4- 3BE790331500 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Of the above, how many non-Hispanic/Latino <br />Total <br />Age <br />0 -5 years <br />6 -18 years <br />19 -50 years <br />51f 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 />capturing <br />this data <br />10 <br />previous <br />year <br />258 <br />300 <br />350 <br />a <br />1 o <br />1 0 <br />5 <br />10 <br />15 <br />258 <br />300 <br />350 <br />299 <br />275 <br />265 <br />75 <br />100 <br />110 <br />632 <br />675 <br />725 <br />5 <br />10 <br />15 <br />2 <br />4 <br />10 <br />150 <br />175 <br />200 <br />100 <br />125 <br />150 <br />Total 1 393 1 479 1 600 <br />ee) 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 (�2pecific, 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 905 meals per <br />day.) <br />PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 24 of 30 <br />118 <br />130 <br />150 <br />5 <br />8 <br />15 <br />10 <br />15 <br />30 <br />2 <br />5 <br />3 <br />10 <br />25 <br />Total 1 393 1 479 1 600 <br />ee) 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 (�2pecific, 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 905 meals per <br />day.) <br />PROGRAM INFORMATION 1/22/2018 10:12:15 AM Page 24 of 30 <br />