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* 1. Are you affiliated with a faith-based hospital?

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* 2. What is your hospital's religious affiliation?

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* 3. How many patients does your hospital treat annually? (optional)

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* 4. What is the total number of staff, clinical and nonclinical, in your hospital? (optional)

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* 5. What kind of LGBTQ outreach/support has your hospital engaged in?

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* 6. Have you seen an increase in the number of LGBTQ patients and/or patients willing to disclose LGBTQ identify since you began your outreach efforts?

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* 7. What kind of engagement and/or outreach was the most effective?

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* 8. My hospital provides an inclusive environment for LGBTQ-identifying employees. 

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* 9. My hospital provides an inclusive environment for LGBTQ identifying patients.

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* 10. My hospital provides equitable, patient-centered care for LGBTQ-identifying patients.

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* 11. What challenges did you encounter in your outreach/engagement?

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* 12. Will you engage in more outreach in the future? If so, what kind of outreach?

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* 13. I would like to hear more about Tanebaum's services and resources.

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* 14. I would like to be signed up for Tanenbaum's weekly newsletter. 

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* 15. Please enter your name.

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* 16. Please enter your e-mail address. 

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