Interested in Becoming a WomenHeart Champion? Complete this questionnaire and take one giant step towards helping women in your community! Survey

Question Title

* 1. Please provide your contact information below.

Name

City/Town

State/Province

Email Address

Phone Number

Question Title

* 2. Are you a woman living with heart disease?

Question Title

* 3. Please enter the name and address of the hospital you would like to recommend for WomenHeart's National Hospital Alliance.

Name of Hospital *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

* 4. Are you a patient at this hospital?

WomenHeart has identified the best individuals in the hospital to contact for this opportunity. Please review this list below and use it as a guide to identify the best person(s) WomenHeart should contact at your hospital. Please choose from the following:

Nurse Administrator
Cardiovascular Service Line (Business) Director
Marketing Director
Head of the Cardiovascular Division (Physician)
Cardiac Rehab Director

Question Title

* 5. Please provide the name and contact information of the individual you would like WomenHeart to contact for this opportunity.

Name

Position

Email Address

Phone Number

Question Title

* 6. If you would like to provide an additional contact person for your hospital, please include his/her information below:

Name

Position

Email Address

Phone Number

Question Title

* 7. Do you have a relationship with the person(s) you referred above?

Question Title

* 8. Would you like to be included in WomenHeart's outreach and presentation to the hospital? If so, you will be contacted via email by a WomenHeart representative.

Question Title

* 9. If your hospital decides to be a leader in its community by advancing women's heart health through our National Hospital Alliance, WomenHeart will train two women with heart disease at an upcoming Science & Leadership Symposium at Mayo Clinic, to lead a patient support group for women with heart disease. If interested and selected for this extraordinary leadership training, would you be available to attend the symposium October 6th - 9th, 2017?

Question Title

* 10. If your hospital has not yet decided to join the National Hospital Alliance and you are a woman living with heart disease, would you be interested in becoming a Community Educator by attending the upcoming Science & Leadership Symposium at Mayo Clinic in Rochester, MN, October 6th - 9th, 2017?

Question Title

* 11. In addition to the National Hospital Alliance, there are many ways you can become empowered and raise awareness of heart disease in your community. Please review the list below and indicate your interest by selecting yes or no for each.

	Yes	No
Become a member and receive key heart health information	Become a member and receive key heart health information Yes	Become a member and receive key heart health information No
Receive one-on-one telepone or email support through our SisterMatch program	Receive one-on-one telepone or email support through our SisterMatch program Yes	Receive one-on-one telepone or email support through our SisterMatch program No
Knit or crochet for our HeartScarves program	Knit or crochet for our HeartScarves program Yes	Knit or crochet for our HeartScarves program No
Attend an in-person Support Network	Attend an in-person Support Network Yes	Attend an in-person Support Network No
Participate in a Virtual or Online Support Network	Participate in a Virtual or Online Support Network Yes	Participate in a Virtual or Online Support Network No
Invite a WomenHeart Champion to your next event to share her story and important heart health information	Invite a WomenHeart Champion to your next event to share her story and important heart health information Yes	Invite a WomenHeart Champion to your next event to share her story and important heart health information No
Join us on social media and become a heart health resource for your social networks	Join us on social media and become a heart health resource for your social networks Yes	Join us on social media and become a heart health resource for your social networks No

Question Title

* 12. Please tell us how you heard about this opportunity below:

Thank you for taking this step towards advancing women's heart health in your community! We will be in touch with you and your hospital with next steps.

Question Title

* 1. Please provide your contact information below.

Question Title

* 2. Are you a woman living with heart disease?

Question Title

* 3. Please enter the name and address of the hospital you would like to recommend for WomenHeart's National Hospital Alliance.

Question Title

* 4. Are you a patient at this hospital?

Question Title

* 5. Please provide the name and contact information of the individual you would like WomenHeart to contact for this opportunity.

Question Title

* 6. If you would like to provide an additional contact person for your hospital, please include his/her information below:

Question Title

* 7. Do you have a relationship with the person(s) you referred above?

Question Title

* 8. Would you like to be included in WomenHeart's outreach and presentation to the hospital? If so, you will be contacted via email by a WomenHeart representative.

Question Title

Question Title

Question Title

* 11. In addition to the National Hospital Alliance, there are many ways you can become empowered and raise awareness of heart disease in your community. Please review the list below and indicate your interest by selecting yes or no for each.

Question Title

* 12. Please tell us how you heard about this opportunity below:

Question Title

* 13. FOR OFFICE USE ONLY: (Do not enter information)