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DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 <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 1 <br />Program Activity, which should be SMART (�jpecific, 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 100 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 />105 meals per day.) <br />Work Statement Chart for Program Club Nova Community, Inc. <br />1. Program Activity Name <br />Club Nova offers a round trip ride for members throughout Orange <br />County six days a week, and on holidays. Transportation is offered with <br />no out -of- pocket charge to members. Club Nova's transportation service <br />ensures each member has equal access to all of our opportunities. <br />Club Nova transportation serves members who live in areas not <br />accessible to public transportation or are unable to utilize the bus system <br />for various reasons (including symptoms related to diagnoses like <br />paranoia) and need viable transportation to Club Nova. <br />Club Nova transportation staff receives necessary training and <br />certification. Staff maintains vehicles. <br />Program Goal <br />Club Nova will maintain a full transportation program that employs and <br />trains 100% of a team of drivers, maintains its vehicles, and provides our <br />membership with approximately 65,000 miles of transportation to and <br />from Club Nova (plus socials and occasional medical appointments) <br />throughout Orange County six days a week and on all major holidays. <br />Performance Measures <br />Club Nova will: <br />• Maintain logs in each vehicle to track ridership and mileage for all trips <br />• Maintain vehicle logs, tracking overall mileage and gas expenditures <br />• Document of certification of all trainings received by drivers (in CPR, <br />AED, 1st Aid, Blood Borne Pathogens, etc.) <br />• Maintain log of social and community events attended by Club Nova <br />members through Club Nova transportation <br />Previous Year Program Results <br />Club Nova provided 64,456 miles of unreimbursed transportation <br />services to members, <br />• 100% of members had access to our transportation services and <br />therefore had access to the rest of our services. (0% were unable to <br />participate due to lack of transportation.) <br />• 80% of Club Nova members utilized transportation opportunities, <br />PROGRAM INFORMATION 1/23/2018 1:58:29 PM Page 23 of 3 1 <br />