Community Health Needs Assessment Contact Form

Community Benefit Inventory - Activity Report

Note: Fields marked with an * indicates required field

Title of Activity: *

Cost Center Number: *

Coordinating Department: *

Contact Person: *

Phone: *

Brief Description of Activity: *

Broad Goals of Activity: *

Is this a collaborative effort outside of McLaren Bay Region? *

Yes

If yes, Please list the organizations:

Is this activity duplicated in the community? *

Yes

Does this activity address any identified, unmet community need? *

Yes

Date of Activity: *

Persons Serviced: *

Hours spent by paid staff: *

Names and Titles of Staff Members: *

Persons Served: *

Hours spent as volunteers: *

Either enter dollars specified, or paid: *

Purchased Services: *

Supplies: *

Other Direct Expenses:

Indirect Expenses:

Support from Foundation/Fundraising:

Grants/Support:

Other: