Stakeholder Mapping Form

Partner Organization Name:

Contact Information (title and department):

Relationship to organization?

Are you a Summa Health employee filling this form out on behalf of a community partnership?

Are you a community partner filling out this form on your behalf?

Are you a company requesting to reach out about a community partnership? Please go to summahealth.org/events-engagement-request

1. Stakeholder Type: (Select all that apply)

Healthcare Provider (Hospital, FQHC, Private Practice, etc.)

Behavioral Health Provider

Nonprofit Organization

Government Agency (Local, State, Federal)

Policymaker (Elected Officials, Public Health Leaders)

Funder (Foundation, Philanthropy, Corporate Sponsor)

Community-Based Organization (CBO)

Education Partner (K-12, Higher Ed, Vocational Training)

Faith-Based Organization

Business Sector (Chamber of Commerce, Employers, Workforce Development)

Other

If you selected other, please provide additional information:

Name, Title, Department:

Contact Information:

Summa Health internal contacts relationship to partnership organization:

Name(s), Title(s), Department(s):

Contact Information:

Secondary contacts relationship to partnership organization:

3. Area of Alignment with Social Drivers of Health then (SDoH) Priorities: (Check all that apply)

Economic Stability: Employment, Income, Food Insecurity, Affordable Childcare, Medical Debt, Workforce Development, Financial Literacy

Education Access & Quality: Literacy, Early Childhood Education, Vocational Training, Higher Ed

Healthcare Access & Quality: Insurance, Provider Availability, Cultural Competency, Quality Care

Neighborhood & Built Environment: Housing, Transportation, Safety, Walkability, Green Spaces

Social & Community Context: Social Support, Discrimination, Inclusion, Civic Engagement, Trauma-Informed Care, Peer Support Networks, Language Access

Other

If you selected other, please provide additional information:

a. Engagement Status:

Not Yet Engaged (No Prior Collaboration)

Initial Discussions Underway

Existing Partnership

Existing Partnership with Growth Potential

b. Patient-Level Collaboration: (Check all that apply)

Memorandum of Understanding (MOU)

Contracted Partner

Referral Arrangement / Case Management

Shared Care Coordination Platform (e.g., Unite Us, EHR interoperability)

Not applicable

c. Community-Level Collaboration: (Check all that apply)

Community Health Needs Assessment (CHNA) Partner

Policy & Advocacy Partnership

Public Health Data Sharing Agreement

Workforce Development Partnership

Joint Grant/Funding Initiative

Summa-Branded Sponsorship

Not applicable

d. Coalition/ Taskforce/ Board Involvement: (Check all that apply)

Serves on Coalition Board or Advisory Group

Engages in Policy Advocacy Efforts

Participates in Summa’s Community Health Initiatives

Not applicable

5. SummaCare Member?

Yes

No

Potential

Unsure

6. Opportunities for Scaling Impact:

Capacity Building Needs

Scaling Successful Models (e.g., replicating food pharmacy success)

Expanding SummaCare’s Reach

No option at this time

Other

If you selected other, please provide additional information:

Key Strengths / Contributions to Community Health:

Potential Areas for Future Collaboration:

Barriers to Engagement: (e.g., funding, staffing, regulations)

Stakeholder Mapping Framework

Partner Organization: Preferred Contact Information

2. Summa Health Internal Contacts:

Secondary Contact(s):

4. Level of Engagement: (Identify existing relationships and gaps)

7. Additional Considerations:

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