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DocuSign Envelope ID:3457204A-7765-4E36-8B42-227F6F673AF6 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. Reintegration Support Network <br /> Work Statement <br /> m) 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, and <br /> actual results. (Add more rows as needed) If this is a new program, you will only document the <br /> projected information. Every program is required to have AT LEAST 1 Program Activity, which <br /> should be SMART (Specific, Measurable, Achievable, _Relevant, and _Time-bound. Click on <br /> 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 100 meals per day, <br /> Monday-Friday.) <br /> • Performance Measures describe how you will evaluate the degree in which you achieved the <br /> 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 achievement <br /> of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per <br /> day.) <br /> Work Statement Chart for Program: Reintegration Support Network <br /> 1. Program Activity Name MentorNolunteers Recruitment <br /> Program Goal Develop community support networks of RSN staff and trained <br /> volunteers to serve in youth-specific support circles that will provide <br /> intensive, long-term, at-home and in-community support to youth in <br /> solidifying their recovery following successful completion of intensive <br /> substance abuse treatment from addiction and co-occurring <br /> disorders. Over the next year, the RSN will engage 6 to 8 youth and <br /> their parents/guardians. The program will be free for recovering <br /> youth and their families. The circle of support will engage with <br /> recovering youth weekly for one year. <br /> RSN will recruit, screen, train, and supervise 18-40 volunteers <br /> (mentors) (3-5 per recovering youth) who will engage in support <br /> circles per grant year along with the program director. <br /> Performance Measures We will have documented the number of volunteers engaged in <br /> supervised recovery support for youth, parents, and program <br /> director. <br /> Previous Year Program Results Program start-up. No mentors/volunteers recruited. <br /> Current Year Estimated Results Will have recruited and engaged 24 mentors/volunteers. <br /> Next Year Projected Results Will have recruited and engaged 48 mentors/volunteers. <br /> 2. Program Activity Name Recovering Youth Engagement and Enlistment <br /> Program Goal Youth completing the program will have solidified sustainable, <br /> enriching, healthy routines that enable them to a) achieve and <br /> solidify positive coping mechanisms b) gain experiential knowledge <br /> and skills that increase their capacities to be self-determining and c) <br /> recognize pathways to maintaining a supportive network and <br /> sobriety. <br /> Performance Measures Collect data from weekly encounter logs from volunteers, youth, <br /> parents, and program director as well as pre-and post-assessments <br /> from youth using screening and assessment tools. <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 12:37:26 PM Page 33 of 45 <br />