Consultation Request Form for Region 5 Opioid Taskforce The Region 5 Opioid Taskforce is comprised of the U.S. Department of Health and Human Services Staff and Operating Divisions. Other federal stakeholders may also be involved, as needed. We welcome the opportunity to support your state, tribe, or organization to identify strategies and resources to combat the opioid epidemic. Please complete the brief information below to allow the Taskforce to review your request and schedule a consultation. Requests will be reviewed by Taskforce members to determine if a consultation is better suited to specific federal agencies or the entire R5 Opioid Taskforce. Submit consultation request and any attachments to: Date: Name of Requesting Organization(s): Point(s) of Contact from Organization(s): Title: Email: Phone: Please submit the following information: Brief Summary of Request (limit to 1-page). List of existing partners addressing this issue and in what capacity. If your community has a strategic opioid plan, please attach. If you have data or references that provide additional context for the please include.
Consultation Request Form for Region 5 Opioid Taskforce The Region 5 Opioid Taskforce is comprised of the U.S. Department of Health and Human Services Staff and Operating Divisions. Other federal stakeholders may also be involved, as needed. We welcome the opportunity to support your state, tribe, or organization to identify strategies and resources to combat the opioid epidemic. Please complete the brief information below to allow the Taskforce to review your request and schedule a consultation. Requests will be reviewed by Taskforce members to determine if a consultation is better suited to specific federal agencies or the entire R5 Opioid Taskforce. Submit consultation request and any attachments to: Date: Name of Requesting Organization(s): Point(s) of Contact from Organization(s): Title: Email: Phone: Please submit the following information: Brief Summary of Request (limit to 1-page). List of existing partners addressing this issue and in what capacity. If your community has a strategic opioid plan, please attach. If you have data or references that provide additional context for the please include.
Region%205%20Opioid%20Taskforce%20Request.docx