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DocuSign Envelope ID: DlA09OF6-2A4E-4FOB-9FB7-92FFFC9El3D2 XHIBIT A: <br /> 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 9 <br /> Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant <br /> and 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 Boomerang <br /> 1. Program Activity Name Alternative to Suspension <br /> Program Goal 85% of students will successfully complete the alternative to <br /> suspension com onent <br /> Performance Measures School referral, daily attendance, qualitative notes on student <br /> participation and behavior, student External Service Note to <br /> schools/courts, internal service notes <br /> Previous Year Program Results 97% - 176 out of 181 referrals <br /> Current Year Estimated Results 85% - 128 out of 150 <br /> Next Year Projected Results 85/0 - 128 out of 150 <br /> 2. Program Activity Name Community Service <br /> Program Goal 50% (15130) of youth will self-report learning/improving skills and <br /> will actively participate in Community Service projects <br /> Performance Measures Community service referral forms, daily timesheets, reports to <br /> Volunteers for Youth and Adult Community Service, youth surveys <br /> Previous Year Program Results 72 individual students performed 381 instances of community <br /> service equaling 720 hours; students participated in 100% of <br /> scheduled community service days at Boomerang—goal has since <br /> been revised <br /> Current Year Estimated Results 50% (15 students) <br /> Next Year Projected Results 50% (15 students) <br /> 3. Program Activity Name What's !Next? <br /> Program Goal 75% of youth attending What's Next?life skills workshops will <br /> report having significantly improved knowledge of subject area <br /> Performance Measures Post-session surveys, focus groups <br /> Previous Year Program Results 67.5% of youth reported having increased knowledge. 6 <br /> workshops were held for high school students and 6 workshops <br /> were held for middle school students. <br /> • 6 What's Next?workshops were held on life skills <br /> development for high school students. <br /> PROGRAM INFORMATION P a g e 15 of 2 0 <br />