Identify three to five leaders to participate on your community partnerships taskforce.

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.)

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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