The application allows saving and returning to your previous responses.  In order for this feature to work properly, you must consistently use the same device and the same web browser you used to start the application, as Survey Monkey stores a cookie on your browser that remembers your survey responses.  We recommend saving a copy of your responses in another format. The bottom of the page lists the additional documents required and instructions to submit your finalized application. 

PLEASE NOTE: this application will be updated in February 2022 following the 5 Baptist Health hospital boards' approval of their hospitals' 2022-2024 prioritized needs. If you are applying between Oct. 1, 2021 - Jan. 31, 2022 and do not see the need you intend to address in Question 13, please contact Jennifer Donahoo at jennifer.donahoo@bmcjax.com for guidance.

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1. Organization

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2. Tax ID#

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3. Website Address

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4. President or Chief Executive Officer

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5. Organizational Mission

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6. Name of Program Requesting Funding

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7. Funding Amount Requested

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8. What is the problem or need addressed by the program?

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9. Contact Person for Application

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10. Signature of Authorized Person
My signature certifies the organization named above has tax exemption under Internal Revenue Service Code Section 501(c)(3). My name in this space indicates I am authorized to sign on behalf of the applying organization.

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11. Indicate the Baptist Health priority and/or the Community Health Needs Assessment prioritized need the program addresses (select all that apply)

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12. Who is your targeted population?

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13. What are the goals and objectives of your program and how does it fit into your organization's overall mission?  Please utilize S.M.A.R.T. attributes.

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14. What the specific measures or data that will demonstrate impact/success?  How will you collect the data?  

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15. If program has been operational in the past, provide outcomes achieved during the previous year. 

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16. What are the titles and qualifications of staff implementing the program?

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17. Identify the biggest challenges or obstacles to successfully implementing the program. How do you plan to overcome them? Are collaborations necessary? 

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18. How many years funding are you requesting?  If more than one, please explain.

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19. If approved, how do you plan to sustain the program once Baptist Health funding ceases?

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20. Does the organization have a board-approved succession plan its executive leader?  Baptist Health funding is contingent upon a board-approved succession plan for its executive leader.

Board Composition - please enter the number of members in each category

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21. Number of board members

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22. Ethnicity

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23. Gender

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24. Race

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25. Optional - comments regarding board diversity

Staff Composition - please enter the number of members in each category

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26. Number of staff members

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27. Ethnicity

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28. Gender

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29. Race

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30. Optional - comments regarding staff diversity

Additional Documents Required:
-Organizational budget
-Program budget - under revenue, include financial requests w/ funder names, amounts & status (seeking or secured), including the Baptist Health request
-List of board members with affiliations and demographics (race, ethnicity, gender)
-Board-approved succession plan or signed certification of board-approved succession plan
-Copy of the tax-exempt status determination letter from the Department of the Treasury, IRS
-Copy of most recently filed IRS Form 990
-Most recent annual report (if available)

To submit:
1. save application 
2. email lynn.sherman@bmcjax.com, copying jennifer.donahoo@bmcjax.com, with the subject line: "Your organization's name - submitting Strategic Investment application"  and attach the documents outlined above

For questions or concerns, please contact:  Lynn Sherman, Director of Community Engagement at lynn.sherman@bmcjax.com or 904.202.5112

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