We value your feedback.

Because of supporters like you, the hospital is providing lifesaving treatment, investing in our communities and helping those who need us most. We couldn’t do it without you, and that’s why we need your input. Please complete our brief survey to help us understand what matters to you.

Step 1 of 12 - Q1

Phone

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1) Which of the following hospitals do you feel most connected to?

Providence Holy Cross Medical Center

Providence Little Company of Mary Medical Centers

Providence Mission Hospital Mission Viejo

Providence Saint Joseph Medical Center Burbank

Providence St. Jude Medical Center

Providence St. Mary Medical Center

Providence Cedars-Sinai Tarzana Medical Center

Providence St. Joseph Hospital Orange

Providence Queen of the Valley Medical Center

Providence Redwood Memorial Hospital

Providence Santa Rosa Memorial Hospital

Providence St. Joseph Hospital Eureka

Petaluma Valley Hospital

Other

Please specify:

2) In what ways have you engaged with the hospital? Please select all that apply.

I was treated at the hospital.

A friend or family member was treated at the hospital.

I am a current or former volunteer at the hospital.

I am a current or former employee of the hospital.

I am a current/former Board Member at the hospital.

I donate.

I have attended events.

I follow on social media.

I have visited the website.

Other

2a) Other - Please specify:

Please specify:

2b) How frequently do you engage with the hospital?

How frequently do you engage with the hospital?

Weekly

Monthly

Every few months

Yearly

Rarely or never

Other

2b-i) Other - Please specify:

Please specify:

3) We like to send friends like you occasional emails with updates including videos, stories and information about how we are making an impact on your behalf. Would you like to receive these updates? (You can opt-out at any time).

Yes, I want to receive occasional emails with updates.

Not at this time.

4) Which of the following hospital community initiatives are most meaningful to you?

Please rank the following according to their importance to you, with First Priority being your highest priority.

You may only select one answer for each option.

First Priority	Second Priority	Third Priority	Fourth Priority	Fifth Priority

Emergency/Trauma

First Priority

Second Priority

Third Priority

Fourth Priority

Fifth Priority

Cancer

First Priority

Second Priority

Third Priority

Fourth Priority

Fifth Priority

Heart & Vascular

First Priority

Second Priority

Third Priority

Fourth Priority

Fifth Priority

Community Benefit/Health Equity

First Priority

Second Priority

Third Priority

Fourth Priority

Fifth Priority

Nursing

First Priority

Second Priority

Third Priority

Fourth Priority

Fifth Priority

Please specify:

5) Was there an influential person in your life who inspired your appreciation of the hospital you identified at the beginning of this survey?

Yes

5a) If yes, please indicate their relationship to you.

If yes, please indicate their relationship to you.

Parent/grandparent

Spouse/partner/significant other

Child/children

Other family member

Friend

Doctor, nurse or other health care provider

Teacher or professor

Other

5a-i) Other - Please specify:

Please specify:

If you feel comfortable, please tell us more about this person.

6) When thinking about future generations, how important is it to you that your preferred hospital remains steadfast in serving all, especially those who are poor and vulnerable?

Of utmost importance

Very important

Somewhat important

Not very important

Not important at all

7) Supporters often recognize the need to help the hospital continue its important work in our community. Would you consider supporting our shared mission in any of the following ways?

I already have	I am likely	I am somewhat likely	I am not likely

Talking with a gift officer to learn more about different ways to give

I already have

I am likely

I am somewhat likely

I am not likely

Donating from a Donor-Advised Fund or Family Foundation

I already have

I am likely

I am somewhat likely

I am not likely

Giving appreciated assets (such as personal or business stocks or bonds, land or rental real estate, etc.)

I already have

I am likely

I am somewhat likely

I am not likely

Donating a portion of my Individual Retirement Account or Required Minimum Distribution

I already have

I am likely

I am somewhat likely

I am not likely

Making a charitable gift that provides a lifetime income to me or my loved ones

I already have

I am likely

I am somewhat likely

I am not likely

8) Many people like to include a gift to charity in their will, trust or other estate plans to support causes that are important in their life. Would you consider creating a legacy at the hospital?

I have included a gift in my will, trust, or by beneficiary designation.

I am interested in making this type of gift.

Not now, but in the future I would definitely be interested in making this type of gift.

Not now, but in the future I might possibly be interested in making this type of gift.

I am not interested in this type of gift.

8a) If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift?

If you feel comfortable sharing, which of the following organizations are a beneficiary of your intended gift?

Providence Holy Cross Medical Center

Providence Little Company of Mary Medical Centers

Providence Mission Hospital Mission Viejo

Providence Saint Joseph Medical Center

Providence St. Jude Medical Center

Providence St. Mary Medical Center

Providence Cedars-Sinai Tarzana Medical Center

Providence St. Joseph Hospital Orange

Providence Queen of the Valley Medical Center

Providence Redwood Memorial Hospital

Providence Santa Rosa Memorial Hospital

Providence St. Joseph Hospital Eureka

Petaluma Valley Hospital

8a-i) Please tell us about your gift:

Please tell us about your gift:

I made this gift to honor or in memory of someone.

I made this gift for a specific purpose.

The hospital may use my gift where it will do the most good.

8a-ii) Please provide the name of and/or association with this person:

Please provide the name of and/or association with this person:

8a-iii) Please describe the intended purpose:

Please describe the intended purpose:

Would you like us to provide additional information to help with your decision?

Easy Ways to Leave a Legacy

How to Create or Update Your Estate Plans

Ways to Make an Impact While Reducing Estate, Capital Gains and Income Taxes

Ways to Make an Impact Now

Gifts That Pay You Income

9) How does the hospital you identified at the beginning of this survey rank in comparison to other charitable causes?

My top choice

Near the top of my list

Middle of my list

Bottom of my list

Not on my list

9a) Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of the hospital?

Do you have any friends/colleagues/family members with similar interests who would consider supporting the mission and vision of the hospital?

Yes

9a-i) Please let us know the most convenient way to connect:

Please let us know the most convenient way to connect:

I would like to introduce the person(s) to the hospital on my own.

I would like the hospital to provide me with resources to share with the person(s).

10) We would love to hear your story. If you would like, please share a special memory from your experience with the hospital.

I prefer to tell you my story directly.

11) About You (optional)

Age

Under 40

40 - 49

50 - 59

60 - 69

70 - 79

80 - 89

90+

Date of Birth

YYYY

Gender

Male

Female

Other/Nonbinary

Prefer not to specify

Please specify:

What is your marital status?

Married

Single

Divorced

Widowed

Which of the following best describes your family?

No children

One child

Two or more children

Please tell us the highest level of education you completed:

High school graduate or equivalent

Some college

Associate's degree

Bachelor's degree

Advanced degree

Please select the option(s) that best describes your professional life.

Working full time

Working part time

Retiring within 5 years

Retired

Volunteering

Board member for a nonprofit

Business owner or entrepreneur

Self-employed

Other

Profession:

Where do you serve as a board member?

Please check the box below if you would like to update your contact information.

I would like to update my contact information.

First name(Required)

Last name(Required)

Address

Address 2

City

State

ZIP

Country

Phone

Email(Required)

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