2011-05-11T10:13:54-05:00 2010-06-30 Deloitte Tax LLP 250 East Fifth Street Suite 1900 Cincinnati OH 45202 990 2009-07-01 310536649 Convalescent Hospital for Children and Orphan Asylum CONV 5136368778 3333 BURNET AVENUE CINCINNATI OH 452293039 SCOTT J HAMLIN 5136368778 2011-05-06 1 5137847100 2009 2016-02-24 21:20:13Z PHILLIP C LONG 3333 BURNET AVENUE CINCINNATI OH 452293039 39000167 0 X N/A X 1833 OH SUPPORT OF CONVALESCENT HOSPITAL FOR CHILDREN 20 18 0 21 0 0 4536 70283 0 -13427750 4021404 0 -13423214 4091687 2549034 2639325 0 0 0 0 256111 268360 2805145 2907685 -16228359 1184002 64321035 68724982 297715 64321035 68427267 THE PURPOSE OF CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM IS TO PROVIDE FINANCIAL SUPPORT TO CONVALESCENT HOSPITAL FOR CHILDREN. 0 0 2639325 2639325 0 CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM ("CHCOA") WAS FORMED FOR THE SOLE PURPOSE OF PROVIDING FINANCIAL SUPPORT TO THE CONVALESCENT HOSPITAL FOR CHILDREN ("CHC"), AN OHIO NOT-FOR-PROFIT PEDIATRIC HOSPITAL. SUCH FINANCIAL SUPPORT IS PROVIDED FROM EXPENDABLE INCOME RECEIVED FROM INVESTMENTS OF RESTRICTED AND UNRESTRICTED FUNDS. IT IS THE POLICY OF CHCOA TO INVEST SUCH ASSETS, THEREBY INCREASING FUND PRINCIPAL AND ENHANCING FUTURE EXPENDABLE INCOME.DURING CHCOA'S FISCAL YEAR OF JULY 1, 2009 THROUGH JUNE 30, 2010 (THE YEAR COVERED BY THIS RETURN), CHCOA PROVIDED FINANCIAL SUPPORT AMOUNTING TO $1,639,325 TO CHC. THESE FUNDS WERE UTILIZED BY CHC TO SUPPORT THE OPERATING COSTS OF ITS PEDIATRIC REHABILITATION PROGRAM, ITS DISABILITY SERVICES PROGRAM, ITS ADOLESCENT PSYCHIATRIC SERVICES PROGRAM, THE SPECIAL NEEDS CHILDREN PROGRAM, ADHD INTAKE AND TRIAGE PROGRAM AND TO SUPPORT THE GENERAL OPERATIONS OF CHC.BECAUSE OF THE DIRECT FINANCIAL SUPPORT OF CHCOA TO CHC, CHC HAS BEEN CONSISTENTLY ABLE TO REINVEST IN ITS PROGRAMS AND MAINTAINS A NATIONAL POSITION AS ONE OF THE LOWEST COST PEDIATRIC HEALTH CARE PROVIDERS IN THE NATION.IN MAY 2006, CHCOA'S BOARD OF TRUSTEES MADE A REVOCABLE $5 MILLION PLEDGE OF UNRESTRICTED PRINCIPAL TO CHILDREN'S HOSPITAL MEDICAL CENTER ("CHMC") TO PROVIDE CAPITAL AND OPERATING SUPPORT OF A RESEARCH AND CLINICAL INITIATIVE KNOWN AS "CHANGE THE OUTCOME". THE PLEDGE IS FOR $1 MILLION A YEAR FOR FIVE YEARS COMMENCING IN FISCAL 2007. 2639325 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 20 18 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 0 0 1 1 0 X SCOTT J HAMLIN 5136368778 3333 BURNET AVENUE CINCINNATI OH 452293039 X PAMELA TERP 1.00 X X 0 0 0 PHILLIP C LONG 1.00 X X 0 0 0 MARIE HUENEFELD 1.00 X X 0 0 0 RONALD SALATIN 1.00 X X 0 0 0 SCOTT HAMLIN 1.00 X X 0 779336 150718 ROBERT H ANNING II 1.00 X 0 0 0 C FRANCIS BARRETT 1.00 X 0 0 0 LEE CARTER 1.00 X 0 0 0 INGRID DAOUD MD 1.00 X 0 0 0 VALLIE GEIER 1.00 X 0 0 0 MARIAN LEIBOLD 1.00 X 0 0 0 DEBBIE LONG 1.00 X 0 0 0 MARIANNE MILLER 1.00 X 0 0 0 JOANIE PAULSEN 1.00 X 0 0 0 WILLIAM K SCHUBERT MD 1.00 X 0 25000 0 SUSAN SHELTON 1.00 X 0 0 0 MARK STEPANIAK 1.00 X 0 0 0 MARKAY WINSTON PhD 1.00 X 0 0 0 ALISON ZIMMERMAN 1.00 X 0 0 0 DAVID GOALD 1.00 X 0 0 0 THOMAS WILLIAMS 1.00 X 0 0 0 0 804336 150718 0 0 1 0 FIFTH THIRD BANK FIFTH THIRD CENTER CINCINNATI OH 45263 INVESTMENT MANAGEMENT 175172 1 70283 70283 1634970 1634970 37294914 34908480 2386434 2386434 2386434 4091687 0 0 4021404 2639325 2639325 268360 268360 2907685 2639325 268360 0 2629772 1227073 61691263 67497909 64321035 68724982 297715 0 297715 X 61824491 65720739 2496544 2706528 64321035 68427267 64321035 68724982 X 0 1 1 X 0 X X X 0 0 0 CHC 310936303 3 1 1 1 1639325 CHMC 310833936 3 0 1 1 1000000 2 2639325 2496544 209984 2706528 3353546 -857002 2496544 0 0 0 4091687 2907685 1184002 2922230 2922230 4106232 7013917 2922230 2922230 4091687 0 4091687 2907685 0 2907685 0 2907685 Part V, Line 4: Description of Intended Use of Endowment Funds: CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM'S ("CHCOA") PERMANENTLY RESTRICTED ENDOWMENT FUNDS ARE RESTRICTED BY DONORS TO BE MAINTAINED BY CHCOA IN PERPETUITY. THESE FUNDS ARE INVESTED AND UTILIZED TO GENERATE EXPENDABLE INCOME THAT CHCOA MAY USE TO PROVIDE FINANCIAL SUPPORT TO CONVALESCENT HOSPITAL FOR CHILDREN, A RELATED ORGANIZATION TO CHCOA. Part X: Description of Uncertain Tax Positions Under FIN 48: IN JULY 2006, THE FINANCIAL ACCOUNTING STANDARDS BOARD ("FASB") ISSUED ASC 740, "INCOME TAXES", WHICH CLARIFIES THE ACCOUNTING FOR UNCERTAINTY IN INCOME TAX POSITIONS. ASC 740 PRESCRIBES A RECOGNITION THRESHOLD AND MEASUREMENT ATTRIBUTE FOR THE FINANCIAL STATEMENT RECOGNITION AND MEASUREMENT OF AN INCOME TAX POSITION TAKEN OR EXPECTED TO BE TAKEN IN A TAX RETURN. ASC 740 ALSO PROVIDES GUIDANCE ON DERECOGNITION, CLASSIFICATION, INTEREST AND PENALTIES, AND ADDITIONAL DISCLOSURES. THE CORPORATION ADOPTED THE PROVISIONS OF ASC 740 IN FISCAL 2010. THE ADOPTION OF ASC 740 IS NOT NOT ANTICIPATED TO HAVE A MATERIAL IMPACT ON THE FINANCIAL STATEMENTS. THE FOLLOWING ARE THE TAX YEARS THAT REMAIN SUBJECT TO EXAMINATION BY MAJOR TAX JURISDICTION: FEDERAL 2007 TO 2010 STATE 2007 TO 2010 1 CONVALESCENT HOSPITAL FOR CHILDREN 3333 BURNET AVENUE CINCINNATI OH 452293039 310936303 501(C)(3) 1639325 FAIR MARKET VALUE GENERAL SUPPORT CHILDREN'S HOSPITAL MEDICAL CENTER 3333 BURNET AVENUE CINCINNATI OH 452293039 310833936 501(C)(3) 1000000 FAIR MARKET VALUE GENERAL SUPPORT 2 0 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: SCHEDULE I, PART I, LINE 2: CHMC SENIOR MANAGEMENT SUBMITS A PROPOSAL FOR FUNDING TO THE CHCOA BOARD OF TRUSTEES. THE CHCOA BOARD REVIEWS THE PROPOSAL AND THEN MAKES A DETERMINATION AS TO WHAT RESEARCH, PATIENT CARE, AND FUNDRAISING PROJECTS WILL BE SUPPORTED WITH CHCOA FUNDING. UPON CHCOA BOARD APPROVAL, FUNDS ARE DISTRIBUTED TO CHMC AND CHC. CHMC SENIOR MANAGEMENT PROVIDES PERIODIC UPDATES TO THE CHCOA BOARD OF TRUSTEES THROUGHOUT THE YEAR INDICATING HOW DONATED FUNDS ARE UTILIZED IN FURTHERANCE OF CHMC'S AND CHC'S CHARITABLE PURPOSES. 0 1 0 0 0 0 0 0 0 SCOTT HAMLIN 0 506025 0 146538 0 126773 0 128518 0 22200 0 930054 0 81201 Part I, Line 4a CERTAIN OFFICERS AND KEY EMPLOYEES OF CHMC, A RELATED ORGANIZATION TO CHCOA, HAVE ARRANGEMENTS WHICH PROVIDE FOR SUPPLEMENTAL RETIREMENT BENEFITS AS DESCRIBED IN IRC SEC. 457(F). DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THESE ARRANGEMENTS ARE NON-VESTED AND THERE IS NO GUARANTEE THAT THESE OFFICERS AND FACULTY MEMBERS WILL EVER RECEIVE THESE BENEFITS. THE FOLLOWING IS A LISTING OF OFFICERS AND KEY EMPLOYEES THAT RECEIVED A DEFERRAL, SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, UNDER CHMC'S IRC SEC. 457(F) PLAN DURING THE YEAR (THESE AMOUNTS ARE INCLUDED IN THE TOTALS FOR SCHEDULE J, PART II, COLUMN C, DEFERRED COMPENSATION): 1. SCOTT HAMLIN - $104,018 THE FOLLOWING IS A LISTING OF OFFICERS AND KEY EMPLOYEES THAT RECEIVED A PAYMENT UNDER CHMC'S IRC SEC. 457(F) PLAN DURING THE YEAR: 1. SCOTT HAMLIN - $81,201 Supplemental Information Part III CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM RELIED ON CHILDREN'S HOSPITAL MEDICAL CENTER ("CHMC"), A RELATED ORGANIZATION, TO ESTABLISH THE COMPENSATION OF INDIVIDUALS LISTED ON FORM 990, PART VII. CHMC USED ONE OR MORE OF THE METHODS DESCRIBED BELOW TO ESTABLISH AN APPROPRIATE LEVEL OF COMPENSATION: COMPENSATION COMMITTEE INDEPENDENT COMPENSATION CONSULTANT FORM 990 OF OTHER ORGANIZATIONS WRITTEN EMPLOYMENT AGREEMENT COMPENSATION SURVEY OR STUDY APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE Explanation of Benefits: The employee benefit plan contribution amountS LISTED ON SCHEDULE J, PART II may include one or more of the following benefits PROVIDED BY CHILDREN'S HOSPITAL MEDICAL CENTER ("CHMC"), A RELATED ORGANIZATION OF CHCOA: 1. Elective employee deferrals under IRC Sec. 403(b) 2. Discretionary employer contributions under IRC Sec. 403(b) 3. Elective employee deferrals under IRC Sec. 457(b) 4. Elective employee deferrals under IRC Sec. 457(f) In addition to the retirement plan contributions disclosed on FORM 9909, PART VII AND SCHEDULE J, PART II, the following non-taxable employee welfare benefits were made available to the employed, compensated officers AND KEY EMPLOYEES listed on FORM 990, PART VII AND SCHEDULE J, PART II: 1. Health AND DENTAL insurance benefits 2. Group life insurance (portions of which are taxed) 3. Unemployment benefits 4. Disability benefits The officers EMPLOYED BY CHMC THAT ARE listed on FORM 990, PART VII AND SCHEDULE J, PART II are also eligible for any other available employee benefits. The organization's executives incur various travel and entertainment expenses in the conduct of their official duties as representatives of the organization. The organization has a written travel and entertainment expense reimbursement policy that complies with published IRS guidance. All executives are required To substantiate each travel and entertainment expense to the extent as stated in the travel and entertainment expense reimbursement policy. Form 990, Part VI, Section A, line 2 C. FRANCIS BARRETT AND MARIAN LEIBOLD HAVE A FAMILY RELATIONSHIP. Form 990, Part VI, Section A, line 2 LEE CARTER AND SUSAN SHELTON HAVE A BUSINESS RELATIONSHIP OUTSIDE OF CHCOA. Form 990, Part VI, Section B, line 11 THE CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM ("CHCOA") FORM 990 IS PREPARED BY SENIOR MANAGEMENT FROM CHILDREN'S HOSPITAL MEDICAL CENTER ("CHMC"), A RELATED ORGANIZATION. EXTERNAL TAX CONSULTANTS THEN REVIEW THE FORM 990 FOR COMPLETENESS AND ACCURACY. THE FORM 990 IS THEN MADE AVAILABLE TO ALL CHCOA BOARD MEMBERS IN ADVANCE OF FILING. Form 990, Part VI, Section B, line 12c ALL OF CHCOA'S BOARD MEMBERS RECEIVE AN ANNUAL QUESTIONNAIRE REQUESTING INFORMATION REGARDING FAMILY AND BUSINESS RELATIONSHIPS THAT COULD POTENTIALLY RESULT IN A CONFLICT OF INTEREST UNDER CHCOA'S CONFLICT OF INTEREST POLICY. ONCE THE QUESTIONNAIRES HAVE BEEN COMPLETED BY ALL OF CHCOA'S BOARD MEMBERS, THE QUESTIONNAIRES ARE REVIEWED AND IF CHCOA DETERMINES THAT A CONFLICT OF INTEREST EXISTS, CHCOA FOLLOWS THE PROVISIONS SET FORTH IN CHCOA'S CONFLICT OF INTEREST POLICY TO RESOLVE THE CONFLICT AND DETERMINES THE APPROPRIATE REPORTING TO BOARD COMMITTEES AND, IF REQUIRED, FORM 990 DISCLOSURE. Form 990, Part VI, Section B, line 15 CHCOA DOES NOT HAVE ANY EMPLOYEES. HOWEVER, CHCOA DOES HAVE OFFICERS THAT ARE EMPLOYED BY CHMC, A RELATED ORGANIZATION. CHMC HAS A COMPENSATION COMMITTEE THAT ANNUALLY REVIEWS THE RECOMMENDATIONS OF CHMC MANAGEMENT REGARDING EMPLOYEE PERFORMANCE EVALUATION AND COMPENSATION ADJUSTMENTS FOR DISQUALIFIED PERSONS TO ENSURE THAT CHMC HAS COMPLIED WITH THE PROVISIONS OF THE REBUTTABLE PRESUMPTION OF REASONABLENESS UNDER IRC SEC. 4958. Form 990, Part VI, Section C, line 19 CHCOA'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MAINTAINED ON FILE BY CHMC SENIOR MANAGEMENT AND ARE AVAILABLE TO THE PUBLIC UPON REQUEST EITHER IN-PERSON, BY TELEPHONE, OR BY WRITTEN REQUEST. FORM 990, PART VI, SECTION B, LINE 14 WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY CHCOA'S BOARD OF TRUSTEES HAS NOT FORMALLY ADOPTED A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY. HOWEVER, CHCOA IS A RELATED ORGANIZATION OF CHMC. CHMC HAS A WRITTEN DOCUMENT RETENTION AND DESTRUCTION POLICY AND CHCOA ABIDES BY THE PROVISIONS OF THIS POLICY. FORM 990, PART VI, SECTION B, LINE 13 WRITTEN WHISTLEBLOWER POLICY CHCOA'S BOARD OF TRUSTEES HAS NOT FORMALLY ADOPTED A WRITTEN WHISTLEBLOWER POLICY. HOWEVER, CHCOA IS A RELATED ORGANIZATION OF CHMC. CHMC HAS A WRITTEN WHISTLEBLOWER POLICY AND CHCOA ABIDES BY THE PROVISIONS OF THIS POLICY. FORM 990, PART VII NUMBER OF HOURS WORKED SCOTT HAMLIN IS EMPLOYED BY CHMC, A RELATED ORGANIZATION. SCOTT DEVOTES AN AVERAGE OF 40 HOURS/WEEK FOR HIS DUTIES TO CHMC AND AFFILIATED ENTITIES. FORM 990, SCHEDULE R TRANSACTIONS WITH RELATED ORGANIZATIONS DURING THE TIME PERIOD COVERED BY THIS RETURN, CONVALESCENT HOSPITAL FOR CHILDREN AND ORPHAN ASYLUM RECEIVED CERTAIN ACCOUNTING AND ADMINISTRATIVE SERVICES FROM CHILDREN'S HOSPITAL MEDICAL CENTER AT NO COST. THE VALUE OF THESE SERVICES IS AN UNSPECIFIED AMOUNT. CONVALESCENT HOSPITAL FOR CHILDREN 3333 BURNET AVE CINCINNATI OH 45229 310936303 PEDIATRIC HEALTHCARE OH 501(C)(3) 3 CHILDREN'S HOSPITAL MEDICAL CENTER 3333 BURNET AVE CINCINNATI OH 45229 310833936 PEDIATRIC HEALTHCARE OH 501(C)(3) 3 N/A 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 CONVALESCENT HOSPITAL FOR CHILDREN B 1639325 CHILDREN'S HOSPITAL MEDICAL CENTER B 1000000