Community Partnership Program

Community Partnership Program: Taskforce Information

Instructions: Identify three to five leaders to participate on your community partnerships taskforce. This interdisciplinary team should be diverse, represents multiple departments, and should be in a director-level or higher leadership role within the organization. You will be presenting this to your executive leadership team. (Please adjust spacing, as needed, for your information.)

 

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Location of Healthcare Facility (Include City and State):

 

Taskforce Leader #1 Information

Taskforce Leader #1(Title or Role):

Reasoning for Taskforce Leader #1:

Special Population Example with a Description of Contribution for Taskforce Leader #1:

 

Taskforce Leader #1: Proposed Partnership Information

Community Partner’s (Organization) Name:

Community Partner’s Website:

Summary of the Community Partner’s Services and/or Products with a Reasoning for Partnership:

 

Taskforce Leader #2 Information

Taskforce Leader #2(Title or Role):

Reasoning for Taskforce Leader #2:

Special Population Example with a Description of Contribution for Taskforce Leader #1:

 

Taskforce Leader #2: Proposed Partnership Information

Community Partner’s (Organization) Name:

Community Partner’s Website:

Summary of the Community Partner’s Services and/or Products with a Reasoning for Partnership:

Taskforce Leader #3 Information

Taskforce Leader #3(Title or Role):

Reasoning for Taskforce Leader #3:

Special Population Example with a Description of Contribution for Taskforce Leader #1:

 

Taskforce Leader #3: Proposed Partnership Information

Community Partner’s (Organization) Name:

Community Partner’s Website:

Summary of the Community Partner’s Services and/or Products with a Reasoning for Partnership:

 

Taskforce Leader #4 Information

Taskforce Leader #3(Title or Role):

Reasoning for Taskforce Leader #3:

Special Population Example with a Description of Contribution for Taskforce Leader #1:

 

Taskforce Leader #4: Proposed Partnership Information

Community Partner’s (Organization) Name:

Community Partner’s Website:

Summary of the Community Partner’s Services and/or Products with a Reasoning for Partnership:

 

Taskforce Leader #5 Information

Taskforce Leader #3(Title or Role):

Reasoning for Taskforce Leader #3:

Special Population Example with a Description of Contribution for Taskforce Leader #1:

 

Taskforce Leader #5: Proposed Partnership Information

Community Partner’s (Organization) Name:

Community Partner’s Website:

Summary of the Community Partner’s Services and/or Products with a Reasoning for Partnership:

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