Baptist Health FY 2022 Strategic Investment Application (Oct. 1, 2021 - Sept. 30, 2022)

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 with the 2022-2024 Community Health Need Priorities in February 2022 following approval by the 5 Baptist Health hospital boards. 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

Name

Street Address

City

Zip Code

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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

Name *

Title

Email Address *

Phone Number *

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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)

All children in Northeast Florida have health care

Adults living in need have access to quality health care

Elderly people live independent, fulfilling lives

Access to Care

Behavioral Health

Maternal and Child Health

Vulnerable Population: LGBT+

Vulnerable Population: Seniors

Other health need (please detail in the comment box below)

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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.

Yes

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

Hispanic

Non-Hispanic

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23. Gender

Female

Male

Transgender

Other

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24. Race

African American/Black

Asian

Native Hawaiian or Other Pacific Islander

White

Other

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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

Hispanic

Non-Hispanic

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28. Gender

Female

Male

Transgender

Other

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29. Race

African American/Black

Asian

Native Hawaiian or Other Pacific Islander

White

Other

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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

Question Title

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.

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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.

Question Title

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

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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

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.