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Please use the drop down menu below to select which function area best aligns with your agency <br />and program(s) in which you are requesting funding. Please select only one from the drop-down <br />menu below. <br />Public Health and Health Education <br />If you selected other, please tell us what function area best aligns with your organization: <br /> <br /> <br />Please indicate three program goals/performance measures below. <br />A few notes: <br />• If you use percentages, please put the actual number equivalence. <br />• Please ensure your performance measures are outcome based and not outputs. <br /> <br />Program Goal # 1 Refugee Health Care <br />Performance Measure <br />(How will you accomplish your goal?) <br />PHS Community Health Center Program will be a primary care <br />home for 600 unduplicated refugee patients over the 2021-2022 <br />grant year. <br />Actual Results <br />(Outcome) <br />Ending FY19-20 <br /> <br />576 refugees <br /> Projected Results <br />(Outcome) <br />Ending FY2021 <br /> <br />600 <br />(304 refugees thus far served between 7/1/20 – 12/31/20) <br /> <br />Projected Results <br />(Outcome) <br />Ending FY2022 <br />600 <br /> <br />Program Goal # 2 Primary Care for Low-Income, Uninsured Patients <br />Performance Measure <br />(How will you accomplish your goal?) <br />PHS Community Health Center program will be a primary care <br />home for >4,000 low income uninsured patients in the 2021-2022 <br />grant period. <br />Actual Results <br />(Outcome) <br />Ending FY19-20 <br /> <br />4,644 <br />Projected Results 4,288 <br /> <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 1139B227-38A3-48CF-BBDF-915390FB071C