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Please select which function area best aligns with your agency and program(s) in which you <br />are requesting funding.Please select only one from the list below: <br />☐ Behavior Health ☑ Public Health & Health Education <br />☐ Food & Nutritional Service ☐ Recreational <br />☐ Housing ☐ Senior Services <br />☐ Human Rights & Community Services ☐ Youth Services <br />☐ Juvenile & Adult Justice Services ☐ Other <br />If you selected other, please tell us what function area best aligns with your organization: <br />N/A <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 />Program Goal # 1 Adolescents will engage with the program and learn <br />new life skills <br />Performance Measure <br />(How will you accomplish <br />your goal?) <br />Number of adolescents who participate in <br />multi-session, evidence-based curricula; average <br />increase in knowledge about pregnancy and STI <br />prevention <br />Actual Results <br />(Outcome) <br />Ending FY2022 <br />24 adolescents; 18.7% change in knowledge <br />(pre-test score avg = 72.6%; post-test score avg <br />86.2%) <br />Projected Results <br />(Outcome) <br />Ending FY2023 <br />25 adolescents; 25% change in knowledge <br />(pre-test score avg = 65%; post-test score avg 81.25%) <br />Projected Results <br />(Outcome) <br />Ending FY2024 <br />25 adolescents; 25% change in knowledge <br />(pre-test score avg = 65%; post-test score avg 81.25%) <br />Program Goal # 2 Parents will have the skills and information they need to <br />talk to their children about sexuality <br />Performance Measure <br />(How will you accomplish <br />your goal?) <br />Number of parents reached through parent workshops; <br />percentage of parents who report an increased comfort <br />in talking about sexuality with their children <br />Actual Results <br />(Outcome) <br />Ending FY2022 <br />6 parents; 100% reporting increased comfort (6/6) <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 33DAB98C-9F47-479D-8E75-67FFA543C9FB