2015-11-16T16:48:59-06:00 2014-12-31 911194016 Clark Nuber PS 10900 NE 4th Suite 1700 Bellevue WA 98004 990 2014-01-01 273133200 GLOBAL TO LOCAL HEALTH INITIATIVE GLOB 2062932485 2800 South 192nd St No 104 SeaTac WA 98188 Adam Taylor Executive Director 2062932485 2015-11-16 1 Sara Elizabeth J Hyre CPA P00235495 4254544919 2014 2016-04-25 22:37:26Z Adam Taylor 2800 South 192nd St No 104 SeaTac WA 98188 458002 0 X www.globaltolocal.org X 2010 WA To promote health in underserved communities. 6 5 0 14 0 0 739104 458002 0 0 0 0 0 0 739104 458002 10000 106023 0 0 0 593039 0 0 0 694300 286093 704300 985155 34804 -527153 784534 391588 219895 370895 564639 20693 X To promote health in underserved communities. 1 0 393534 4900 0 G2L's Community Health Promoters are individuals recruited from the communities they serve who provide support for improved nutrition and physical activity with the goal of preventing and/or better managing chronic diseases--particularly diabetes. In 2014 CHPs served approximately 1100 people. 143760 17500 0 G2L's mobile health program provides mobile phone-based support for people who are living with diabetes. G2L staff manage patients via text messaging and support them to make healthy lifestyle changes that will improve their management of diabetes, reduce complications, and reduce costs to the health care system. This program served 40 patients in 2014. 135967 65000 0 Food Innovation District (See Part III, Line 2 Narrative). In 2014, G2L connected approximately 40 individuals to training to support them in developing a business. 99904 0 0 The Global To Local(G2L) Connection Desk connects patients and the broader community with social services that ensure better health. This includes health insurance enrollment, food assistance, job search support, transportation assistance, housing assistance, and much more. In 2014, the connection desk served approximately 4000 clients. 42946 18623 0 G2L's Leadership Development program provides mentoring and support for community members who want to work on behalf of building a healthy community. In 2014, G2L provided over 1400 hours of mentoring for nearly 30 community leaders. 142850 18623 0 816111 1 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0 0 0 1 X 46 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 X Karl E Fritschel CPA 4255253339 1801 Lind Avenue SW 9016 Renton WA 980579016 X Dixon Dan President 10.00 30.00 X X 0 279106 87441 Cohen Lisa Treasurer 2.00 0.00 X X 0 0 0 Trumpeter Tom Secretary 2.00 0.00 X X 0 0 0 Fleming David Director 2.00 0.00 X 0 0 0 Yohalem Lisa Director 2.00 0.00 X 0 0 0 Fontinos Charissa Director 2.00 0.00 X 0 0 0 Taylor Adam Exec Director 40.00 0.00 X 0 124429 0 0 403535 87441 0 0 1 0 HealthPoint 955 Powell Ave SW Renton WA 98057 Contract Labor 483363 King County Public Health 401 Fifth Avenue 1000 Seattle WA 98104 Contract Labor 124429 2 12765 183160 262077 35572 458002 458002 0 0 0 X 69900 69900 36123 36123 124429 62214 62215 366109 311449 54660 61753 41757 19996 40748 28524 12224 198050 198050 19707 13795 5912 34472 24130 10342 4535 4535 698 698 3935 938 2997 Program Supplies 24696 24696 985155 816111 169044 0 106119 146313 600000 221711 78415 6874 16690 0 16690 784534 391588 159895 219559 60000 151336 219895 370895 X 564639 20693 564639 20693 784534 391588 -527153 -16793 0 X X 0 0 0 X 16533 1063214 98867 739104 458002 2375720 83026 83026 99559 1063214 98867 739104 458002 2458746 362905 2095841 2458746 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 16690 16690 16690 1 Pinchot University 220 2nd Avenue S Suite 400 Seattle WA 98104 912157623 501(C)(3) 65000 Provide Food Business Training to Low Income Participants 1 0 Incentive for Outreach Work 53 36123 0 Community Health Outreach Part I, Line 2: The Board of Directors reviews grant applications, assesses the needs and determines the amount of resources to award other organizations in support of Global To Local's missions. 0 1 0 0 0 0 0 0 0 Dixon Dan President 0 261900 0 0 0 17206 0 68668 0 18773 0 366547 0 0 Part I, Line 4b NON-QUALIFIED RETIREMENT PLANS: A) SERP = Supplemental Executive Retirement Plan 1) Dan Dixon a) SERP Earned but not Vested - $51,517 b) SERP Interest Credit - $5,452 Form 990, Part VII Section A Dan Dixon is a paid employee of Providence Health & Services, a related organization. He is not compensated for serving as a Director or Officer of Global To Local Health Initiative. Form 990, Part VII Section A Compensation for Adam Taylor, Executive Director, is paid by King County Public Health as a reimbursement to Global To Local. X Cell Phones 1 18882 FMV X Furniture 2 16690 FMV 0 0 1 0 Part I, Column (b): The amounts shown on Part I, Col. B reflect the number of donations received of the specific type of item. Program startup expenses 2014-12-31 65000 Cost 912157623 Pinchot University 220 2nd Ave 400 Seattle WA 98104 501(c)(3) Other program expenses Cost 0 0 0 0 SCHEDULE N - SUBSTANTIAL CONTRACTION This organization is not dissolving. The substantial contraction is merely due to the expenditures associated with the startup of a new program and expenses previously paid by a related organization. Form 990, Part III, line 2 Global To Local(G2L) increased support for creating a Food Innovation District. This program provides a multi-purpose facility including classrooms and commercial kitchen space for trainings as well as community members interested in starting their own food-related businesses (e.g., catering, small-scale food processing). Form 990, Part VI, Section A, line 6 Swedish Health Services, Public Health Seattle & King County, HealthPoint Community Health Clinics, and Washington Global Health Alliance are the members of Global To Local Health Initiative. Form 990, Part VI, Section A, line 7a Each of the four members of Global To Local Health Initiative can appoint two of the (maximum) eight members of the Board. Form 990, Part VI, Section A, line 7b Swedish Health Services has unilateral authority to dissolve the organization if it determines that the activities of Global To Local Health Initiative will jeopardize its exempt status or any of its members' exempt status. Form 990, Part VI, Section B, line 11 The Form 990 is prepared internally by experienced staff and reviewed by the internal Director of Taxes and external tax advisors. The President will review the Form 990 in detail. Once approved, an electronic copy of the Form 990 is emailed to the Board prior to filing with the IRS. Form 990, Part VI, Section B, line 12c The Board of Directors has adopted a conflict of interest policy. Board members and covered persons are required to complete a conflict of interest questionnaire annually and disclose any affiliations, interest or relationship, and/or any transactions the individual and/or his or her family members have engaged in that might give rise to an actual, apparent or potential conflict of interest. The policy defines family members and describes what constitutes conflicts of interest. It requires individuals to report to the appropriate committee chair any further financial interest, situation, activity, interest or conduct that may develop before completion of the next annual questionnaire. The conflict of interest questionnaire includes an annual statement that board members and covered persons (a) have received a copy of the policy, (b) have read and understood the policy, (c) agree to comply with the policy, (d) understand that the policy applies to committees and subcommittees, (e) understand that the organization is a charitable organization that must engage primarily in exempt activites, (f) agree to report to the appropriate manager or committee chair any change to matters previously disclosed on the conflict of interest questionnaire, (g) state that the information provided in the conflict of interest questionnaire is true and accurate to the best of his or her knowledge and belief. The purpose of the policy is to ensure board members and covered persons are independent and able to perform their duties in an impartial manner, free from any bias created by personal interests, to protect the interests of the organization, to clarify the duties and obligations of the board members and covered persons in the context of a potential conflict (and to provide a method for disclosing and resolving said conflict), and to supplement (not replace) any applicable state laws governing conflicts of interest applicable to charitable, nonprofit corporations. The organization will not engage in any contract, transaction or arrangement involving a potential conflict of interest unless it is determined that appropriate safeguards protect the charitable mission of the organization have been implemented. The executive committee will review all conflict of interest questionnaires for board members. The executive committee will make a finding as to whether an actual, apparent or potential conflict of interest exists and will take actions as it deems appropriate. The conflict of interest committee governs the policy and questionnaire related to all other covered persons. The minutes of meetings will identify any person attending the meeting who has a conflict of interest with respect to any matter before the board or committee and the action taken to address the conflict of interest (e.g., the individual left the room during the discussion of the matter giving rise to the conflict of interest and the individual did not vote on such matter). Form 990, Part VI, Section C, line 19 Copies of Global To Local Health Initiative's governing documents, conflict of interest policy, and financial statements are available upon request. Form 990, Part IX, line 11g Miscellaneous: Program service expenses 5,404. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,404. Babysitting: Program service expenses 12,701. Management and general expenses 0. Fundraising expenses 0. Total expenses 12,701. Leadership Program-SeaTac/Tukwila: Program service expenses 3,630. Management and general expenses 0. Fundraising expenses 0. Total expenses 3,630. Video Production: Program service expenses 5,000. Management and general expenses 0. Fundraising expenses 0. Total expenses 5,000. Urban Food Link-Food Innovation Project: Program service expenses 40,227. Management and general expenses 0. Fundraising expenses 0. Total expenses 40,227. Community Health Promoters: Program service expenses 54,816. Management and general expenses 0. Fundraising expenses 0. Total expenses 54,816. Connection Desk: Program service expenses 30,596. Management and general expenses 0. Fundraising expenses 0. Total expenses 30,596. Mobile Health: Program service expenses 16,876. Management and general expenses 0. Fundraising expenses 0. Total expenses 16,876. Consultant for Economic Development: Program service expenses 28,800. Management and general expenses 0. Fundraising expenses 0. Total expenses 28,800. Form 990, Part VI, Section B, Line 13 Global To Local Health Initiative is subject to the written whistleblower policy of Swedish Health Services. Form 990, Part VI, Section B, Line 14 Global To Local Health Initiative is subject to the written document retention and destruction policy of Swedish Health Services. FORM 990, SCHEDULE R - RELATED ORGANIZATIONS AFFILIATION AGREEMENTS Effective March 1, 2014, Providence Health System entered into an affiliation agreement with Sisters of Charity of Leavenworth Health System (SCL) to transfer sponsorship of Saint John's Health Center (Saint John's) to the Health System. Saint John's operates a nonprofit medical center, a cancer institute, and physician clinics to serve the Santa Monica, California community and surrounding area. Effective May 1, 2014, the Health System entered into an affiliation agreement with PacMed Clinics (PacMed). PacMed is a private, nonprofit, multi-specialty medical group with nine clinics in the Puget Sound area and more than 150 primary care and specialty providers at the date of affiliation. Pursuant to the affiliation agreement, Western HealthConnect became PacMed's sole corporate Member. No cash or other purchase consideration was transferred to effect the affiliation. Effective June 13, 2014, the Health System entered into an affiliation agreement with Kadlec Health System (Kadlec). Kadlec operates a nonprofit medical center, a neurological resource center, a supporting foundation, and physician clinics to serve the tri-cities area of Kennewick, Pasco, and Richland, Washington. Pursuant to the affiliation agreement, Western HealthConnect became the sole member of Kadlec. No cash or other purchase consideration was transferred to effect the affiliation. Form 990 line 6 -Volunteers Volunteers serve in various capacities: * Community outreach and engagement * Recruitment for community health activities * Organizing and leading community health activities (walking groups, fitness groups) * Providing childcare * Providing administrative and clerical support * Providing logistical support for health screenings * Translation and interpretation * Database design * IT support * Transportation of program participants * Health insurance enrollment * Resource referral for accessing health and human services Providence Health & Services - Washington 1801 Lind Avenue SW 9016 Renton WA 980579016 510216586 Healthcare System WA 501( c)(3) Line 3 Providence Health & Services 0 Providence Health & Services - Oregon 1801 Lind Avenue SW 9016 Renton WA 980579016 510216587 Healthcare System OR 501( c)(3) Line 3 Providence Health & Services 0 Providence Health System - So California 1801 Lind Avenue SW 9016 Renton WA 980579016 510216589 Healthcare System CA 501( c)(3) Line 3 Providence Health & Services 0 Everett Transitional Care Services PO Box 5128 Everett WA 982065128 943264605 Transitional Care WA 501( c)(3) Line 9 N/A 0 Providence Oregon Management Corporation 1801 Lind Avenue SW 9016 Renton WA 980579016 930813977 Shell Corporation OR 501( c)(3) Line 1 PH & S - 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Oregon 0 The Gamelin California Association 540 23rd St Oakland CA 94612 911293869 Housing CA 501( c)(3) Line 9 PHS - So California 0 Gamelin Washington Association 1423 First Avenue Seattle WA 98101 201910170 Housing WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Foundation 1801 Lind Avenue SW 9016 Renton WA 980579016 943078543 Support PH&S Institutions WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Alaska Foundation 3300 Providence Drive - B Tower2 Anchorage AK 99508 920093565 Support PHS-Alaska AK 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence St Peter Foundation 413 Lilly Road NE Olympia WA 985065166 911097056 Support Affiliated Tax-Exempt Organization WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Health Care Foundation (Centralia) 914 S Scheuber Road Centralia WA 98531 911433382 Support Providence Centralia Hospital WA 501( c)(3) Line 7 PH & S - Washington 0 Providence Mount St Vincent Foundation 4831 - 35th Avenue SW Seattle WA 981262799 911188119 Support Providence Mount St.Vincent WA 501( c)(3) Line 7 PH & S - 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Oregon 0 Providence St Vincent Medical Foundation 9205 SW Barnes Rd Portland OR 97225 930575982 Support Providence St. Vincent Medical Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Milwaukie Foundation 10150 SE 32nd Milwaukie OR 97222 943079515 Support Providence Milwaukie Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Child Center Foundation 830 NE 47th Portland OR 97213 930800140 Support Providence Child Center OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence TrinityCare Hospice Foundation 5315 Torrance Blvd Suite B1 Torrance CA 90503 330261016 Support TrinityCare Hospice CA 501( c)(3) Line 7 PHS - So California 0 Providence Little Company of Mary Foundation 4101 Torrance Blvd Torrance CA 90503 510224944 Support Little Company of Mary Service Area CA 501( c)(3) Line 7 PHS - So California 0 PH&S FoundationSFVSA & SCVSA 501 S Buena Vista Street Burbank CA 91505 953544877 Support Program & Activities of SFVSA & SCVSA CA 501( c)(3) Line 7 PHS - So California 0 Providence Hospice of Seattle Foundation 425 Pontius Avenue North 300 Seattle WA 981095452 912077378 Support Hospice of Seattle WA 501( c)(3) Line 11/Type I PH & S - 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Ministries in E. WA. WA 501( c)(3) Line 7 PH & S - Washington 0 St Patrick Hospital Foundation 500 West Broadway PO Box 4587 Missoula MT 598064587 237056976 Support Healthcare in W. Montana MT 501( c)(3) Line 7 PH & S - Washington 0 University of Great Falls 1301 20th Street South Great Falls MT 59405 810231777 Post Secondary Education MT 501( c)(3) Line 2 PH & S - Washington 0 E WA & MT Unemployment Compensation Insurance Trust 1801 Lind Avenue SW 9016 Renton WA 980579016 911082119 Unemployment Benefits WA 501( c)(3) Line 11/Type I PH & S - Washington 0 Providence Willamette Falls Medical Foundation 1500 Division Street Oregon City OR 97045 931003750 Support Willamette Falls Hospital OR 501( c)(3) Line 11/Type I PH & S - Oregon 0 Providence Hood River Memorial Hospital Foundation Inc 811 13th St Hood River OR 97031 930921990 Support Providence Hood River Memorial Hospital OR 501( c)(3) Line 7 PH & S - Oregon 0 Providence Hospice and Home Care Foundation 2731 Wetmore Avenue Suite 500 Everett WA 98201 272552749 Support Program & Ministries of PHHC WA 501(c )(3) Line 7 PH & S - Washington 0 Providence St Mary Foundation 401 W Poplar St Walla Walla WA 99362 452841492 Support Program & Ministries of SMMC WA 501(c )(3) Line 7 PH & S - 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MOB CA N/A Prov Radiation Oncology Develop Assn LLC 4400 NE Halsey 495 Portland OR 97213 260682491 Real Estate - MOB OR N/A Providence Partners for Health LLC 501 S Buena Vista St Burbank CA 91505 454041798 Clinical Quality & Integration CA N/A ProvidenceSilverton Rehab LLC 4400 NE Halsey 425 Portland OR 97213 481287267 Rehab Services OR N/A Southern Idaho Regional Laboratory LLC 611 N Perry Spokane WA 99202 820511819 Outpatient Lab ID N/A Mountainstar Clinical Laboratories LLC 611 N Perry Spokane WA 99202 261345983 Outpatient Lab MT N/A Tri-Cities Laboratory LLC 611 N Perry Spokane WA 99202 911773986 Outpatient Lab WA N/A Providence Health Ventures Inc 4101 Torrance Blvd Torrance CA 90503 330122216 Investment CA N/A C 0 Caron Health Corporation 510 W Front St Missoula MT 59802 810486082 Medical Physician Service MT N/A C 0 Providence Health Care Ventures Inc 101 W 8th Ave TAF C-9 Spokane WA 99204 900155714 Clinical/Medical Lab WA N/A C 0 Providence Physician Services Co 101 W 8th Ave TAF C-9 Spokane WA 99204 911216033 Clinical/Medical Lab WA N/A C 0 Yakima Medical Arts Inc 611 N Perry 100 Spokane WA 99202 910787963 Rental Real Estate WA N/A C 0 Bourget Health Services Inc PO Box 2687 Spokane WA 99220 911354431 Clinical/Medical Lab WA N/A C 0 1221 Madison Street Owners Assoc 747 Broadway Seattle WA 98122 201954319 Owners' Association WA N/A C 0 Washington Cancer Centers PC 1560 N 115th G-16 Seattle WA 98133 911792791 Cancer Treatment WA N/A C 0 Western HealthConnect Ventures Inc 1801 Lind Ave SW 9016 Renton WA 98057 800953654 Investment WA N/A C 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0