2012-11-13T16:47:38-06:00 2011-12-31 391214345 KOLBCO SC 13400 BISHOPS LANE SUITE 300 BROOKFIELD WI 53005 990 2011-01-01 391500074 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC CHIL 4142665420 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 WELDON GAGE 4142665420 2012-11-08 1 BRYAN L PAUTSCH CPA P00034913 2627549400 2012-11-13 2011 2016-02-24 21:20:13Z PEGGY TROY 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 94634962 0 X WWW.CHW.ORG X 1985 WI INTEGRATED AND COORDINATED HEALTH SERVICES NETWORK FOR INFANTS, CHILDREN AND ADOLESCENTS. 24 18 636 3850 413031 15407 13600714 13557884 74260183 80082979 279709 326861 875430 667238 89016036 94634962 471296 303897 0 0 47534061 48857138 0 0 0 41136912 46114465 89142269 95275500 -126233 -640538 77799339 72842210 15566603 18966118 62232736 53876092 X CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS") IS COMMITTED TO ENSURING A HEALTHIER FUTURE FOR CHILDREN BY PROVIDING AN INTEGRATED AND COORDINATED HEALTH AND SOCIAL SERVICES NETWORK FOR INFANTS, CHILDREN AND ADOLESCENTS. 0 0 55609647 297395 65373018 CHHS IS THE PARENT ORGANIZATION OF AN INTEGRATED SYSTEM OF ENTITIES PROVIDING COMPREHENSIVE MEDICAL CARE AND SOCIAL SERVICES TO CHILDREN FROM WISCONSIN AND THROUGHOUT THE MIDWEST. THE SYSTEM INCLUDES WISCONSIN'S ONLY FREESTANDING HOSPITAL DEDICATED SOLELY TO THE CARE AND TREATMENT OF CHILDREN, AS WELL AS VARIOUS OTHER FACILITIES PROVIDING INPATIENT AND OUTPATIENT CARE FOR CHILDREN WITH ALL TYPES OF ILLNESSES, INJURIES, BIRTH DEFECTS AND OTHER DISORDERS. THE SYSTEM ALSO INCLUDES EXTENSIVE RESEARCH, EDUCATION AND COMMUNITY OUTREACH PROGRAMS. ON AN AGGREGATE BASIS, THE ENTITIES WITHIN THE SYSTEM PROVIDED COMMUNITY BENEFITS OF OVER $100 MILLION.CHHS OVERSEES AND COORDINATES THE ACTIVITIES OF THE VARIOUS OPERATING ENTITIES WITHIN THE INTEGRATED SYSTEM, INCLUDING THROUGH THE PROVISION OF SUPPORTIVE AND ADMINISTRATIVE SERVICES ON A CONSOLIDATED, CENTRALIZED BASIS. 12231718 844860 CHILDREN'S RESEARCH INSTITUTE ("CRI") IS A PROGRAM OF CHHS THAT ADVANCES PEDIATRIC MEDICAL RESEARCH IN WISCONSIN AND BEYOND. WITH A FOCUS ON TRANSLATIONAL RESEARCH, THE CRI IS TAKING DISCOVERIES FROM THE LABORATORY AND CONVERTING THEM TO NEW THERAPIES AT PATIENTS' BEDSIDES. RESEARCHERS AT THE CRI CONTINUE TO INVESTIGATE IMMUNE RESPONSES TO CANCER CELLS. SPECIFICALLY, RESEARCHERS ARE STUDYING NEUROBLASTOMAS, A FORM OF CHILDHOOD CANCER THAT APPEARS AS A TUMOR MASS, FOCUSING THEIR RESEARCH ON INTERFERING WITH THE "TRICKS" THIS CANCER USES TO AVOID DETECTION BY THE IMMUNE SYSTEM. IN ADDITION TO CONTINUED RESEARCH EFFORTS IN THE LABORATORY, CHILDREN'S HOSPITAL OF WISCONSIN, A CHHS AFFILIATE, WAS DESIGNATED AS A PHASE 1 CENTER BY THE CHILDREN'S ONCOLOGY GROUP. THIS DESIGNATION ALLOWS PATIENTS THE OPPORTUNITY TO PARTICIPATE IN EARLY-PHASE CLINICAL RESEARCH WHEN PATIENTS NO LONGER BENEFIT FROM TRADITIONAL CANCER TREATMENTS.THE CRI ALSO CONTINUES TO FOCUS RESEARCH EFFORTS ON THE POTENTIAL OF HUMAN STEM CELLS. IN 2011, A CRI RESEARCHER RECEIVED A $6.3 MILLION NATIONAL INSTITUTES OF HEALTH GRANT TO STUDY HUMAN HEART CELLS, SPECIFICALLY, TO UNDERSTAND THE GENETIC FACTORS LEADING TO AN INCREASE IN THE SIZE AND WEIGHT OF THE HEART, KNOWN AS LEFT VENTRICULAR HYPERTROPHY (LVH) WHICH IS COMMON IN PATIENTS WITH HIGH BLOOD PRESSURE, OBESITY, AND KIDNEY FAILURE. WITH THE INCREASING NUMBER OF CHILDREN WITH KIDNEY DISEASE, OBESITY, DIABETES, AND COMPLEX CARDIAC PROBLEMS, USING HUMAN STEM CELLS TO FURTHER UNDERSTAND THE MECHANISMS THAT LEAD TO LVH MAY LEAD TO NEW DRUGS AND TREATMENT FOR LVH. 8933808 13299437 CHHS PROVIDES VARIOUS OUTPATIENT HEALTH CARE SERVICES. IN 2011, THERE WERE 21,395 VISITS TO THE ORGANIZATION'S URGENT CARE CLINICS, AND 5,850 OUTPATIENT SURGICAL CASES PERFORMED AT THE ORGANIZATION'S AMBULATORY SURGICAL CENTER, THE SURGICENTER OF GREATER MILWAUKEE, LLC (A DISREGARDED ENTITY FOR FEDERAL TAX PURPOSES). 5908564 6502 565664 OTHER PROGRAMS OF CHHS INCLUDE THE OUTCOMES ANALYSIS SERVICES AT NATIONAL OUTCOMES CENTER ("NOC") AND HEALTH EDUCATION SERVICES AT CHILDREN'S HEALTH EDUCATION CENTER ("CHEC"). NOC PROVIDES PROFESSIONAL SERVICES ON A CONTRACTUAL BASIS FOR DATA MANAGEMENT AND ANALYSIS SERVICES AND REVIEWS OF CLINICAL OUTCOMES PURSUANT TO HEALTH RELATED STUDIES FOCUSED ON ENHANCING MORE EFFECTIVE AND EFFICIENT DELIVERY OF HEALTH CARE.CHEC OFFERS FREE AND INEXPENSIVE HEALTH EDUCATION PROGRAMS AND RESOURCES TO TEACHERS, CHILDREN AND PARENTS. PROGRAMS OFFERED INCLUDE IN-CLASSROOM PROGRAMS ON HEALTHY EATING AND EXERCISE, BULLYING AND TEEN DEPRESSION, IN ADDITION TO FIELD TRIPS AT OUR BRIGHT AND ENGAGING FACILITY. CHEC ALSO HAS INJURY PREVENTION PROGRAMS WHICH FOCUS ON CAR SEAT AND BIKE HELMET FITTINGS, TO KEEP CHILDREN SAFE AND HEALTHY. ADDITIONALLY, CHEC OFFERS HEALTH-BASED E-LEARNING PROGRAMS THROUGH BLUEKIDS.ORG WHICH HELPS STUDENTS MAKE MORE POSITIVE HEALTH CHOICES. ADDITIONALLY, CHHS PROVIDES SCHOOL-BASED HEALTH CENTERS IN MILWAUKEE SCHOOLS. THESE CENTERS PROVIDE PREVENTATIVE CARE, PHYSICALS, IMMUNIZATIONS AND TREATMENT FOR ILLNESSES TO AN AREA THAT PREVIOUSLY DID NOT HAVE PEDIATRICIAN PRACTICES AVAILABLE TO ATTEND TO THE COMMUNITY'S NEEDS. IN 2011, THERE WERE 14,574 SCHOOL-BASED NURSE ENCOUNTERS WHICH INCLUDED 1,001 VISION AND HEARING SCREENINGS. 5908564 6502 565664 82683737 1 1 0 1 0 0 0 0 1 1 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 1 0 0 0 1 0 0 0 0 1 1 1 1 0 0 1 41 0 636 1 1 1 0 0 0 0 0 0 0 0 0 X 24 18 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X MR JASON PELSIS 4142665997 9000 W WISCONSIN AVENUE MILWAUKEE WI 53201 WILLIAM J ABRAHAM JR 1.00 X 0 0 0 MICHAEL W ALTSCHAEFL 1.00 X 0 0 0 THOMAS M BOLGER 1.00 X 0 0 0 ELIZABETH BRENNER 1.00 X 0 0 0 CURT S CULVER 1.00 X 0 0 0 DAVID J DRURY 1.00 X X 0 0 0 DAVID H GILBERT 1.00 X 0 0 0 SUSAN HERMA 1.00 X 0 0 0 MARK R HOGAN 1.00 X 0 0 0 PAUL W JONES 1.00 X 0 0 0 JOSEPH KERSCHNER MD 1.00 X 0 0 0 KEVIN MANSELL 1.00 X 0 0 0 C DAVID MYERS 1.00 X 0 0 0 ALBERT S ORR III 1.00 X 0 0 0 MICHAEL T PEPKE 1.00 X 0 0 0 J JOEL QUADRACCI 1.00 X 0 0 0 LARRY A RAMBO 1.00 X 0 0 0 JAY O ROTHMAN 1.00 X 0 0 0 JOHN E SCHLIFSKE 1.00 X 0 0 0 JOHN S SHIELY 1.00 X 0 0 0 PETER M SOMMERHAUSER 1.00 X X 0 0 0 OWEN J SULLIVAN 1.00 X 0 0 0 TIMOTHY W SULLIVAN 1.00 X 0 0 0 PAUL SWEENEY 1.00 X 0 0 0 MARK C WITT 1.00 X 0 0 0 MARGARET TROY 40.00 X X 1179464 0 273322 TIMOTHY L BIRKENSTOCK 40.00 X 758474 0 35788 MARC CADIEUX 40.00 X 249193 0 22555 CINTHIA S CHRISTENSEN 40.00 X 0 657222 86773 ROBERT DUNCAN 40.00 X 321938 0 61407 JULIET KERSTEN 40.00 X 60533 170402 40442 MICHELLE METTNER 40.00 X 236407 0 33267 MICHAEL NAUMAN 40.00 X 480648 0 66417 MARGARET NIEMER 40.00 X 347401 0 65196 SHEILA REYNOLDS 40.00 X 386500 0 71192 RAMESH SACHDEVA MD 40.00 X 405469 0 67050 ROBERT SANDERS 40.00 X 272900 0 50893 DENISE AUGUSTIN 40.00 X 161646 0 33592 THOMAS DUNIGAN MD 40.00 X 296140 104752 39441 MARK ANDERSON 40.00 X 217560 0 22464 MARK RAKOWSKI 40.00 X 213970 0 40562 VERONICA GUNN 40.00 X 210795 0 27640 LUCIA ROMAN-MARCIAL 40.00 X 191645 0 16876 JAMES MILLER 40.00 X 0 465450 71182 MARTIN VOGEL 40.00 X 0 271240 37650 JON E VICE 0.00 X 261357 0 0 6252040 1669066 1163709 66 1 1 0 MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK RD MILWAUKEE WI 53226 RESEARCH, EDUCATION, MEDICAL LEADERSHIP 9139727 DELOITTE CONSULTING LLP PO BOX 7247-6447 PHILADELPHIA PA 191706447 CONSULTING AND MANAGEMENT FEES 2581346 PARAGON DEV SYS INC PO BOX 88079 MILWAUKEE WI 532880079 COMPUTER MAINTENANCE SUPPLIES & SOFTWARE 1843483 MICROSOFT LICENSING GP 1401 ELM ST 5TH FLR DEPT 842467 DALLAS TX 75202 SOFTWARE LICENSING AND MAINTENANCE FEES 1652220 ALLSCRIPTS HEALTHCARE LLC LOCKBOX 077153 PHILADELPHIA PA 191710133 SOFTWARE MAINTENANCE FEES 1637108 44 13220528 251698 85658 13557884 OPER SUPPORT SERVICES 541900 65373018 63822405 413031 1137582 OUTPATIENT HEALTH CARE 621400 13299437 13299437 RESEARCH ADMIN FEE 900099 844860 844860 DATA MGMT & ANALYSIS 541900 482439 482439 CHEC FEES 900099 83225 83225 80082979 197419 197419 129442 0 129442 129442 129442 EDUCATIONAL SERVICES 611430 248845 248845 418393 418393 667238 94634962 79199604 413031 1464443 250080 250080 53817 53817 6902506 5932396 970110 30392237 25978101 4414136 1494921 1281401 213520 7523821 6477354 1046467 2543653 2167004 376649 67740 200 67540 393715 354453 39262 272012 239969 32043 225181 198655 26526 37770 15250 22520 8529500 7287327 1242173 293463 276324 17139 739052 597497 141555 9215943 8098095 1117848 3638077 3107900 530177 1402926 1225403 177523 270442 228079 42363 4466253 3940825 525428 785484 592066 193418 RESEARCH 5660232 5660232 PURCHASED SERVICES 3352603 3079849 272754 MEDICAL SUPPLIES 1762872 1754343 8529 SUBSCRIPTION & DUES 880144 761695 118449 4121056 3125422 995634 95275500 82683737 12591763 0 7713704 1481883 357989 366562 1658235 1606901 28000 21000 69500 467897 439776 3973287 5218454 72839132 21535697 54769173 51303435 6590694 8838054 5737005 77799339 72842210 10075345 13548825 4001 0 86837 190604 5400420 5226689 15566603 18966118 X 60318449 51862520 1490112 1776104 424175 237468 62232736 53876092 77799339 72842210 X -640538 -7716106 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 296103 296103 89624640 89920743 1000000 250000 0 0 1000000 1000000 1000000 1000000 4000000 6000000 592525 374061 282225 296103 1544914 250000 250000 250000 250000 1000000 1500000 1 158994 430166 371494 217666 0 1914287 843860 1271 745000 846 2013572 1614564 1249343 30138 978936 822 1914287 1614564 1614564 0.00000 0.11800 0.88200 0 1 1 1457978 1457978 49859117 9768429 40090688 1857222 1635570 221652 19362229 10073857 9288372 302586 57841 244745 51303435 DUE FROM AFFILIATES 358955 DEFERRED COMPENSATION PLAN ASSETS 2125191 BENEFICIAL INTEREST IN NET ASSETS OF CHILDREN'S HOSP. & HEALTH SYSTEM FOUND. 2013572 INVESTMENT IN VIRTUAL PICU SYSTEMS, LLC 403861 INVESTMENT IN NORTH SHORE SURGERY CENTER 826426 INVESTMENT IN MED-HEALTH FINANCIAL SERVICES, INC. 9000 5737005 DEFERRED COMPENSATION PLAN LIABILITY 2125191 RETIREMENT PLAN LIABILITY 3101498 5226689 PART IV, LINE 1B: CERTAIN EMPLOYEES OF THE ORGANIZATION HAVE SIGNING AUTHORITY FOR THE CHECKING ACCOUNT OF THE CENTER FOR INTERNATIONAL HEALTH, INC. ("CIH"). ADDITIONALLY, CERTAIN EMPLOYEES OF THE ORGANIZATION HAVE SIGNING AUTHORITY FOR THE CHECKING ACCOUNT OF THE WELFARE AUXILIARY OF CHILDREN'S HOSPITAL OF WISCONSIN, INC. ("WA"). THE ORGANIZATION ALSO PROVIDES ACCOUNTING FUNCTIONS FOR WA. THE AMOUNTS IN PART IV ARE THE COMBINED TOTALS FOR THESE TWO INDIVIDUAL ACCOUNTS. DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION, INC., A RELATED ENTITY, HOLDS ENDOWMENT FUNDS ON BEHALF OF CHHS. INTENDED USES OF THE ENDOWMENT FUNDS INCLUDE VARIOUS HEALTH-EDUCATION RELATED PROJECTS. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: FOOTNOTE 2 INCOME TAXES: CHHS EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS AND THERE HAVE BEEN NO UNCERTAIN TAX POSITIONS RECORDED IN 2011 OR 2010. 1 CENTER FOR FAMILIES 2120 FORDEM AVE MADISON WI 53704 391624393 501(C)(3) 48861 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM FAMILY RESOURCE CENTER OF SHEBOYGAN 1209A EASTERN AVENUE PLYMOUTH WI 53073 391857835 501(C)(3) 46000 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM FAMILY RESOURCE CENTER OF NORTHEAST WISCONSIN PO BOX 22308 GREEN BAY WI 54305 390827320 501(C)(3) 56000 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM LACAUSA 136 W GREENFIELD AVENUE MILWAUKEE WI 53204 391247667 501(C)(3) 31485 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM LAKESHORE COMMUNITY ACTION PROGRAM 540 N 8TH ST PO BOX 2315 MANITOWOC WI 54221 391214392 501(C)(3) 40850 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM SEXUAL ASSAULT CRISIS CENTER 35 PARK PLACE SUITE 100 APPLETON WI 54914 391309331 501(C)(3) 19051 ANNUAL GRANT FOR A CHILD ABUSE PREVENTION PROGRAM 6 0 PROJECT MANAGEMENT FOR HOME VISITATION OUTCOMES PROJECT 3 47315 N/A SCHOLARSHIPS 11 6502 N/A PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: MONITORING PROCEDURES - THE CHILD ABUSE PREVENTION FUND IS COMMITTED TO ENSURING A SAFE ENVIRONMENT FOR CHILDREN THROUGH FINANCIAL SUPPORT OF PRIMARY PREVENTION ACTIVITIES THROUGHOUT WISCONSIN, AS WELL AS EDUCATING PROFESSIONALS AND THE PUBLIC ABOUT THE ROLE OF PREVENTION IN ELIMINATING CHILD ABUSE. THE CHILD ABUSE PREVENTION FUND IS A SPECIAL FUNDRAISING INITIATIVE OF CHHS. THE FUND'S FOCUS IS ON OUTCOMES OR RESULTS FOR FAMILIES, CHILDREN AND COMMUNITIES. AGENCIES THAT RECEIVE FUNDING MEET CRITERIA FOR EFFECTIVENESS AND ACCOUNTABILITY. EACH ORGANIZATION FUNDED IS EXPECTED TO DEMONSTRATE POSITIVE OUTCOMES THROUGH SIX-MONTH AND ANNUAL PROGRESS REPORTS. IN MANY CASES, CHHS STAFF OVERSEE AND PLAY A ROLE IN HELPING ORGANIZATIONS DEMONSTRATE POSITIVE OUTCOMES. CHHS STAFF ALSO PERFORM SITE VISITS. SCHEDULE I, PART III: SCHOLARSHIPS AWARDED TO RECIPIENTS ARE PAID DIRECTLY TO THE EDUCATIONAL INSTITUTIONS. X X X X X X 1 1 0 0 0 0 0 1 0 MARGARET TROY 736762 0 336229 0 106473 0 241301 0 32021 0 1452786 0 70103 0 TIMOTHY L BIRKENSTOCK 163222 0 130024 0 465228 0 20500 0 15288 0 794262 0 118537 0 MARC CADIEUX 169387 0 66000 0 13806 0 15600 0 6955 0 271748 0 0 0 CINTHIA S CHRISTENSEN 0 389948 0 118956 0 148318 0 58566 0 28207 0 743995 0 42557 ROBERT DUNCAN 256603 0 35930 0 29405 0 35790 0 25617 0 383345 0 0 0 JULIET KERSTEN 37441 157813 22974 0 118 12589 3278 13768 4499 18897 68310 203067 0 12066 MICHELLE METTNER 193076 0 42908 0 423 0 12898 0 20369 0 269674 0 0 0 MICHAEL NAUMAN 329635 0 91641 0 59372 0 43440 0 22977 0 547065 0 13132 0 MARGARET NIEMER 229686 0 61349 0 56366 0 43397 0 21799 0 412597 0 18981 0 SHEILA REYNOLDS 237263 0 68372 0 80865 0 44305 0 26887 0 457692 0 21941 0 RAMESH SACHDEVA MD 287819 0 65997 0 51653 0 42150 0 24900 0 472519 0 15854 0 ROBERT SANDERS 186531 0 51524 0 34845 0 29199 0 21694 0 323793 0 17554 0 DENISE AUGUSTIN 124880 0 19485 0 17281 0 12005 0 21587 0 195238 0 0 0 THOMAS DUNIGAN MD 201134 104752 63660 0 31346 0 27818 2888 5291 3444 329249 111084 19917 0 MARK ANDERSON 163310 0 0 0 54250 0 13553 0 8911 0 240024 0 23117 0 MARK RAKOWSKI 180231 0 27750 0 5989 0 17054 0 23508 0 254532 0 0 0 VERONICA GUNN 210399 0 0 0 396 0 8249 0 19391 0 238435 0 0 0 LUCIA ROMAN-MARCIAL 180575 0 0 0 11070 0 0 0 16876 0 208521 0 0 0 JAMES MILLER 0 310117 0 56375 0 98958 0 45950 0 25232 0 536632 0 28801 MARTIN VOGEL 0 195144 0 33438 0 42658 0 18050 0 19600 0 308890 0 13339 JON E VICE 0 0 0 0 261357 0 0 0 0 0 261357 0 259360 0 PART I, LINES 4A-B UNTIL MARCH 2011, TIMOTHY BIRKENSTOCK SERVED AS TREASURER & CFO OF CHHS. CHHS PAID CERTAIN AMOUNTS AS SEVERANCE INCOME TO MR. BIRKENSTOCK PURSUANT TO A WRITTEN AGREEMENT. CASH PAYMENTS MADE TO MR. BIRKENSTOCK IN 2011 TOTALED $329,655. PART I, LINE 4B: IN 2011, THERE WAS A CHHS FLEXIBLE BENEFIT PLAN IN PLACE WHICH WAS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (457(F)). THE ORGANIZATION CONTRIBUTES 7% OF EACH PARTICIPATING EXECUTIVE'S SALARY. THE AMOUNTS OF EMPLOYER CONTRIBUTIONS TO THIS PLAN FOR PARTICIPATING EXECUTIVES IN 2011 WERE AS FOLLOWS: M. TROY $52,472; C. CHRISTENSEN $38,066; R. DUNCAN $27,540; M. NAUMAN $35,190; M. NEIMER $25,347; S. REYNOLDS $26,255; R. SACHDEVA, M.D. $29,509; R. SANDERS $20,949; T. DUNIGAN, M.D. $10,206; J. MILLER $32,800. AFTER A VESTING PERIOD, PARTICIPANTS MAY ELECT TO WITHDRAW AMOUNTS PREVIOUSLY CONTRIBUTED AND REPORTED. AMOUNTS WITHDRAWN BY PARTICIPANTS IN 2011 WERE: M. TROY $70,103; T. BIRKENSTOCK $118,537; C. CHRISTENSEN $42,557; J. KERSTEN $12,066; M. NAUMAN $13,132; M. NEIMER $18,981; S. REYNOLDS $21,941; R. SACHDEVA, M.D. $15,854; R. SANDERS $17,554; T. DUNIGAN, M.D. $19,917; M. ANDERSON $23,117; J. MILLER $28,801; M. VOGEL $13,339; J. VICE $259,360. CHHS HAS REPORTED ADDITIONAL AMOUNTS SET ASIDE FOR A NONQUALIFIED RETIREMENT PLAN ON BEHALF OF ITS PRESIDENT AND CEO. THE AMOUNT SET ASIDE IN 2011 WAS $180,579. PART I, LINE 7 CERTAIN EXECUTIVES PARTICIPATE IN AN ANNUAL BONUS PLAN THAT PROVIDES COMPENSATION BASED ON ACHIEVING SPECIFIC PRE-DEFINED GOALS. BONUS CRITERIA ARE ESTABLISHED ON AN EXECUTIVE-BY-EXECUTIVE BASIS. SUCH CRITERIA PERTAIN TO MATTERS WITHIN THE EXECUTIVE'S AREA OF RESPONSIBILITY, AS WELL AS ACHIEVEMENT OF OVERALL STRATEGIC OBJECTIVES OF THE ORGANIZATION AND ITS AFFILIATES. SUPPLEMENTAL INFORMATION PART III FORM 990, PART VII, COLUMN E AND SCHEDULE J, PART II: SALARIES PAID BY RELATED ORGANIZATIONS: 1. CINTHIA CHRISTENSEN, PRESIDENT OF CHW AND EXECUTIVE VICE PRESIDENT OF CHHS - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SUPERVISORY SERVICES PROVIDED (40 HOURS PER WEEK) TO CHW AND AFFILIATES. THESE AMOUNTS WERE PAID BY CHW. 2. JULIET KERSTEN, VP AMBULATORY & REGIONAL SVCS - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHW AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHW. 3. THOMAS DUNIGAN, M.D., PEDIATRIC PHYSICIAN, PRESIDENT OF CMG (THROUGH JULY 2011) AND PRESIDENT AND TREASURER OF CHILDREN'S PHYSICIAN GROUP, P.C. ("CPG") - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CMG AND CPG. THESE AMOUNTS WERE PAID BY CMG. 4. JAMES MILLER, PRESIDENT AND CEO OF CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION, INC. ("CHHSF") - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHHSF. THESE AMOUNTS WERE PAID BY CHHSF. PRIOR TO 2011, MR. MILLER'S COMPENSATION FOR SERVICES AS PRESIDENT AND CEO OF CHHSF WAS PAID BY CHHS AND ALLOCATED TO CHHSF. AS A RESULT, MR. MILLER WAS REPORTED AS A HIGHLY COMPENSATED EMPLOYEE OF CHHS IN PREVIOUS YEARS. 5. MARTIN VOGEL, VICE PRESIDENT OF PRINCIPAL GIFTS OF CHHSF - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID FOR SERVICES PROVIDED (40 HOURS PER WEEK) TO CHHSF. THESE AMOUNTS WERE PAID BY CHHSF. PRIOR TO 2011, MR. VOGEL'S COMPENSATION FOR SERVICES AS VICE PRESIDENT OF PRINCIPAL GIFTS OF CHHSF WAS PAID BY CHHS AND ALLOCATED TO CHHSF. AS A RESULT, MR. VOGEL WAS REPORTED AS A HIGHLY COMPENSATED EMPLOYEE OF CHHS IN PREVIOUS YEARS. M CADIEUX EDUCATION LOAN X 28000 28000 0 0 1 28000 HUMANA DIRECTOR (L. RAMBO) 153341 MR. RAMBO IS THE REGIONAL CHIEF EXECUTIVE OFFICER OF HUMANA, INC. THE ORGANIZATION PAID HUMANA FOR TPA SERVICES FOR ITS SELF-INSURED HEALTH PLAN IN THE AMOUNT OF $153,341. 0 HUMANA DIRECTOR (L. RAMBO) 1029721 MR. RAMBO IS THE REGIONAL CHIEF EXECUTIVE OFFICER OF HUMANA, INC. THE ORGANIZATION RECEIVED APPROXIMATELY $1,029,721 FROM HUMANA FOR HEALTH CARE SERVICES PROVIDED TO HUMANA ENROLLEES. 0 FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIPS EXIST BETWEEN THE FOLLOWING BOARD MEMBERS: ABRAHAM AND QUADRACCI; ABRAHAM AND ROTHMAN; ALTSCHAEFL AND PEPKE; BRENNER AND DRURY; BRENNER AND O. SULLIVAN; DRURY AND SOMMERHAUSER; DRURY AND SCHLIFSKE; DRURY AND O. SULLIVAN; SCHLIFSKE AND SOMMERHAUSER; SOMMERHAUSER AND HERMA; O. SULLIVAN AND KERSCHNER; BRENNER AND KERSCHNER; CULVER AND KERSCHNER; AND BRENNER AND CULVER. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 WAS REVIEWED BY THE AUDIT AND COMPLIANCE COMMITTEE OF THE CHHS BOARD OF DIRECTORS, AND PRIOR TO FILING, A COPY WAS PROVIDED TO ALL DIRECTORS OF CHHS. FORM 990, PART VI, SECTION B, LINE 12C ANNUALLY, ALL MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS AND KEY EMPLOYEES ARE REQUIRED TO SUBMIT A CONFLICT OF INTEREST DISCLOSURE TO THE CORPORATE VICE PRESIDENT AND GENERAL COUNSEL. A LIST OF POTENTIAL CONFLICTS IS PREPARED AND IS AVAILABLE AT EACH BOARD AND COMMITTEE MEETING. THE COMPLIANCE DEPARTMENT MONITORS AND PERIODICALLY REVIEWS TRANSACTIONS BETWEEN THE ORGANIZATION AND BOARD MEMBERS OR ENTITIES WITH WHICH THEY ARE AFFILIATED. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION OF THE ORGANIZATION'S CEO AND SENIOR OFFICERS, WITH THE EXCEPTION OF THE INTERIM TREASURER / CFO, THE VP OF GOVERNMENT RELATIONS, THE VP OF AMBULATORY & REGIONAL SERVICES, AND THE SURGICENTER EXECUTIVE DIRECTOR, WAS REVIEWED AND APPROVED BY THE INDEPENDENT COMPENSATION COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS. WITH THE ASSISTANCE OF AN INDEPENDENT COMPENSATION CONSULTANT AND INFORMATION FROM A VARIETY OF EXTERNAL SOURCES (AS INDICATED ON SCHEDULE J), THE COMMITTEE CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS FOLLOWED BY THE COMMITTEE, INCLUDING THE DATA RELIED UPON AND THE COMMITTEE'S DECISIONS, WAS THOROUGHLY AND TIMELY DOCUMENTED. COMPENSATION OF OTHER OFFICERS AND THE KEY EMPLOYEE WAS SET BY SUPERVISORY EXECUTIVES IN CONSULTATION WITH CHHS HUMAN RESOURCES LEADERS. THE PROCESS INVOLVED REVIEW BY INDEPENDENT PERSONS WHO CONFIRMED THAT TOTAL COMPENSATION AMOUNTS TO BE PAID WERE REASONABLE AND COMPARABLE TO AMOUNTS PAID BY SIMILARLY SITUATED ORGANIZATIONS. THE PROCESS AND DATA RELIED ON WERE THOROUGHLY AND TIMELY DOCUMENTED. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL INFORMATION OF CHHS ARE AVAILABLE TO THE PUBLIC UPON REQUEST TO THE CHHS PUBLIC RELATIONS DEPARTMENT. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -115,391. NET ASSET/CASH TRANSFER TO CHILDREN'S COMMUNITY HEALTH PLAN, INC. -7,700,000. INCREASE IN BENEF. INTEREST IN NET ASSETS OF CHILDREN'S HOSPITAL FOUNDATION 99,285. TOTAL TO FORM 990, PART XI, LINE 5: -7,716,106. FORM 990, PART V, LINE 1A: THE ORGANIZATION DID NOT FILE ANY 1099 FORMS DURING THE TAXABLE YEAR. ALTHOUGH THE ORGANIZATION DID RETAIN INDEPENDENT CONTRACTORS, THE COMPENSATION AMOUNTS OWED TO SUCH CONTRACTORS WERE PROCESSED AND PAID BY A RELATED ENTITY, CHW, WITH APPROPRIATE INTERCOMPANY ARRANGEMENTS BETWEEN THE ORGANIZATION AND CHW. THE 1099 FORMS FOR SUCH PAYMENTS WERE ISSUED BY CHW, AS THE ENTITY THAT PROCESSED AND MADE THE PAYMENTS TO THE INDEPENDENT CONTRACTORS. THE 1099 FORMS LISTED IN PART V ARE THE FORMS FILED BY THE ORGANIZATION'S DISREGARDED ENTITY. 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