2011-11-10T09:51:13-06:00 2010-12-31 KOLBCO SC 13400 BISHOPS LANE SUITE 300 BROOKFIELD WI 53005 990 2010-01-01 390812532 CHILDREN'S HOSPITAL OF WISCONSIN INC CHIL 4142665420 9000 W WISCONSIN AVE PO BOX 1997 NO MS 900 MILWAUKEE WI 53201 MARC CADIEUX 4142665420 2011-10-31 1 BRYAN L PAUTSCH 2627549400 2011-10-31 2010 2016-03-07 17:11:31Z MARGARET TROY 9000 W WISCONSIN AVE PO BOX 1997 NO MS 90 MILWAUKEE WI 53201 635028209 0 X WWW.CHW.ORG X 1894 WI PEDIATRIC HEALTH CARE SERVICES 25 17 3774 375 183349 -17738 17287587 19245594 557886987 524038329 5879898 8315179 7672860 7847097 588727332 559446199 466781 495578 0 0 221114802 212227531 0 0 0 292652523 305533639 514234106 518256748 74493226 41189451 1082493881 1153583040 387505204 403541346 694988677 750041694 X THE MISSION OF CHILDREN'S HOSPITAL OF WISCONSIN, INC. IS TO PROVIDE A COMPREHENSIVE AND INTEGRATED PEDIATRIC HEALTH CARE MODEL THAT DELIVERS SUPERIOR QUALITY AND VALUE BY OFFERING THE BEST SOLUTION FOR THE TOTAL HEALTH CARE NEEDS OF CHILDREN WITHIN OUR COMMUNITY, STATE AND REGION.AS A PREMIER AND STANDARD-SETTING LEADER IN THE DELIVERY OF PEDIATRIC CLINICAL SERVICE, EDUCATION AND RESEARCH, CHILDREN'S HOSPITAL ADVOCATES FOR CHILDREN AND BRINGS A COMMITMENT TO EXCELLENCE TO OUR PATIENTS AND FAMILIES, MEDICAL STAFF, EMPLOYEES AND COMMUNITIES IN ADDRESSING THE HEALTH AND WELL-BEING OF CHILDREN.OUR MISSION IS OUR CHILDREN (AND IT SPELLS "CARE"):CAREGIVING - OFFERING HIGH QUALITY, COMPREHENSIVE MEDICAL CAREADVOCACY - SPEAKING UP AND PROTECTING CHILDRENRESEARCH - FINDING CURES TO THE ILLNESSES THAT AFFECT CHILDRENEDUCATION - SHARING WHAT WE LEARN AND TEACHING OTHERS TO CARE FOR KIDS 0 0 428156005 495578 524038329 INPATIENT SERVICES:CHILDREN'S HOSPITAL OF WISCONSIN, INC. ("CHW" OR "THE HOSPITAL") OPERATES A 296-BED HOSPITAL AT ITS MILWAUKEE CAMPUS, WHICH INCLUDES AN EMERGENCY ROOM OPEN ON A 24/7 BASIS. IT IS A FREESTANDING WISCONSIN HOSPITAL DEDICATED SOLELY TO THE CARE AND TREATMENT OF CHILDREN AND IS ONE OF THE LEADING CENTERS FOR PEDIATRIC HEALTH CARE IN THE U.S. THE HOSPITAL SERVES CHILDREN WITH ALL TYPES OF ILLNESSES, INJURIES, BIRTH DEFECTS AND OTHER DISORDERS. THE HOSPITAL PROVIDES ACUTE LEVEL SERVICES, AS WELL AS EMERGENCY AND SPECIALTY CARE, TO CHILDREN FROM WISCONSIN, THE UPPER PENINSULA OF MICHIGAN, NORTHERN ILLINOIS AND BEYOND. IN 2010, 24,615 CHILDREN WERE ADMITTED TO THE MILWAUKEE CAMPUS, WHICH INCLUDES A NEONATAL INTENSIVE CARE UNIT (NICU), PEDIATRIC INTENSIVE CARE UNIT (PICU), A HEMATOLOGY, ONCOLOGY, AND TRANSPLANT UNIT, MEDICAL/SURGICAL UNITS, AND A DAY SURGERY SHORT STAY UNIT. THE HOSPITAL ALSO OPERATES A SEPARATELY-LICENSED 42-BED PEDIATRIC HOSPITAL, WHICH INCLUDES A NICU AND A PEDIATRIC MEDICAL/SURGICAL UNIT, LOCATED ON THE CAMPUS OF THEDA CLARK MEDICAL CENTER IN NEENAH, WIS., THROUGH WHICH IT PROVIDES PEDIATRIC EXPERTISE TO THE GREATER FOX VALLEY AREA.OUTPATIENT AND AMBULATORY SERVICES:THE HOSPITAL PROVIDES A FULL ARRAY OF OUTPATIENT SURGICAL, DIAGNOSTIC AND AMBULATORY SERVICES, INCLUDING MORE THAN 70 SUBSPECIALTY CLINICS PROVIDING OUTPATIENT DIAGNOSIS AND TREATMENT FOR A WIDE VARIETY OF PEDIATRIC DISORDERS. THE HOSPITAL IS A CERTIFIED LEVEL 1 PEDIATRIC TRAUMA CENTER, AND HANDLED 61,928 VISITS DURING 2010. OTHER OUTPATIENT SERVICES ARE OFFERED AT ACCESSIBLE LOCATIONS THROUGHOUT SOUTHEASTERN WISCONSIN AND NORTHERN ILLINOIS, AND IN WISCONSIN'S FOX VALLEY. THE HOSPITAL'S NATIONALLY KNOWN AND RECOGNIZED SPECIALTY PROGRAMS INCLUDE THOSE FOR TREATING CHILDREN WITH AIRWAY, DIGESTIVE AND VOICE CONDITIONS; BURNS; CANCER AND BLOOD DISORDERS; CONGENITAL AND ACQUIRED HEART DEFECTS AND DISEASES; CRANIOFACIAL DISORDERS; DERMATOLOGY, BIRTHMARKS AND VASCULAR ANOMALIES; DIABETES; GASTROINTESTINAL PROBLEMS; GENETIC DISORDERS; HIV; NEUROLOGICAL DISORDERS; ORTHOPEDIC CONDITIONS; IMMUNODEFICIENCIES AND IMMUNE DYSREGULATION SYNDROMES; PSYCHIATRY; SLEEP DISORDERS; ORGAN TRANSPLANTATION; SPEECH AND HEARING DISORDERS; AND SPASTICITY AND OTHER TONE AND MOBILITY CONDITIONS. THE HOSPITAL PROVIDES PRIMARY CARE, DENTAL CARE AND CHILD PROTECTIVE SERVICES TO DISADVANTAGED AND UNDERPRIVILEGED CHILDREN THROUGH CLINICS IN DOWNTOWN MILWAUKEE. THE HOSPITAL ALSO OFFERS CASE MANAGEMENT SERVICES AND A FULL RANGE OF MEDICAL, PSYCHOLOGICAL, NURSING AND SOCIAL SERVICES FOR CHILDREN WITH DEVELOPMENTAL, BEHAVIORAL AND LEARNING PROBLEMS.RESEARCH, EDUCATION AND COMMUNITY OUTREACH:THE HOSPITAL CARRIES ON EXTENSIVE RESEARCH, EDUCATION AND COMMUNITY OUTREACH PROGRAMS.IN COLLABORATION WITH ACADEMIC INVESTIGATORS AT THE MEDICAL COLLEGE OF WISCONSIN, MARQUETTE UNIVERSITY, UNIVERSITY OF WISCONSIN-MADISON AND OTHER INSTITUTIONS, THE HOSPITAL AND CHILDREN'S RESEARCH INSTITUTE PARTICIPATE IN AN ARRAY OF RESEARCH INITIATIVES SEEKING TO IMPROVE THE DIAGNOSIS AND TREATMENT OF CONGENITAL AND ACQUIRED PEDIATRIC HEALTH CONDITIONS. THESE RESEARCH INITIATIVES INCLUDE, FOR EXAMPLE, BEHAVIORAL HEALTH, EPILEPSY AND OTHER NEUROLOGICAL CONDITIONS; ORGAN TRANSPLANTATION; BIRTH DEFECTS AND FETAL ANOMALIES; IMMUNOLOGICAL CONDITIONS, BLOOD DISORDERS AND VARIOUS CHILDHOOD CANCERS; AND ENVIRONMENTAL HEALTH CONDITIONS. NURSING RESEARCH ALSO IS CARRIED ON AT THE HOSPITAL, INCLUDING, FOR EXAMPLE, STUDIES REGARDING PAIN MANAGEMENT, QUALITY OF LIFE, COPING SKILLS, FAMILY READINESS AND SEDATION PROTOCOLS.THE HOSPITAL IS A MAJOR TEACHING AFFILIATE OF THE MEDICAL COLLEGE OF WISCONSIN, WITH THIRD- AND FOURTH-YEAR MEDICAL STUDENTS ROTATING THROUGH THE HOSPITAL FOR REQUIRED AND ELECTIVE ROTATIONS. THE HOSPITAL ALSO HAS A THREE-YEAR PEDIATRIC RESIDENCY PROGRAM, A TWO-YEAR DENTAL TRAINING PROGRAM AND ACADEMIC FELLOWSHIP PROGRAMS IN AN ARRAY OF SPECIALTIES. THE HOSPITAL HAS RELATIONSHIPS WITH OVER TWO DOZEN UNIVERSITIES FOR THE CLINICAL PEDIATRIC EDUCATION OF NURSING AND OTHER HEALTH CARE PROFESSIONAL STUDENTS, AS WELL AS HEALTH CARE ADMINISTRATION STUDENTS AND VARIOUS OTHER DISCIPLINES. THE HOSPITAL'S PEDIATRIC SPECIALISTS ALSO PROVIDE EDUCATION AND TRAINING TO HEALTH CARE PROFESSIONALS AT COMMUNITY HOSPITALS, PRIMARY CARE CLINICS AND SCHOOLS THROUGHOUT WISCONSIN IN CONNECTION WITH THE IDENTIFICATION, DIAGNOSIS AND TREATMENT OF PEDIATRIC HEALTH AND WELFARE CONDITIONS. THE HOSPITAL PARTICIPATES IN A WIDE VARIETY OF COMMUNITY EDUCATION, OUTREACH AND CHILD HEALTH ADVOCACY PROGRAMS. THROUGH COMMUNITY EDUCATION PROGRAMS ON TOPICS SUCH AS CHILD HEALTH, INJURY PREVENTION, PARENTING, MANAGEMENT OF CHRONIC DISEASES, AND PREVENTIVE HEALTH, THE HOSPITAL REACHES OUT TO THOUSANDS OF FAMILIES THROUGHOUT THE GEOGRAPHIC REGION. ALONG WITH THE MEDICAL COLLEGE, THE HOSPITAL SPONSORS THE CENTER FOR THE ADVANCEMENT OF URBAN CHILDREN, WHICH SEEKS TO IMPROVE THE HEALTH AND WELL-BEING OF URBAN CHILDREN. THE HOSPITAL PARTICIPATES IN THE CHILDREN'S HEALTH ALLIANCE OF WISCONSIN, THROUGH WHICH PROVIDERS AROUND THE STATE WORK COLLABORATIVELY TO RAISE AWARENESS OF CHILDREN'S HEALTH ISSUES, INCREASE ACCESS TO PEDIATRIC CARE, AND PROMOTE BEST PRACTICES. OTHER COMMUNITY OUTREACH AND ADVOCACY INITIATIVES INCLUDE, FOR EXAMPLE, CAR SEAT CLINICS, THE DANIEL M. SOREF FAMILY RESOURCE CENTER, A FETAL CONCERNS PROGRAM, AND PROJECT ADAM (EDUCATION AND PREVENTION INITIATIVES IN THE AREA OF PEDIATRIC SUDDEN CARDIAC DEATH). 428156005 1 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 1 0 0 1 604 0 3774 1 1 1 0 0 0 0 0 0 0 0 0 X 25 17 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 WI X MR JASON PELSIS 4142665997 9000 W WISCONSIN AVE 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 ROBERT M KLIEGMAN MD 1.00 X 0 0 0 MARLENE MELZER LANGE MD 1.00 X 35000 0 0 C DAVID MYERS 1.00 X 0 0 0 KEITH T OLDHAM MD 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 MARK C WITT 1.00 X 0 0 0 MARGARET TROY 40.00 X X 0 997755 247005 CINTHIA S CHRISTENSEN 40.00 X 516425 0 82730 TIMOTHY L BIRKENSTOCK 40.00 X 0 596957 81491 SHEILA REYNOLDS 40.00 X 0 353276 64317 LAWRENCE DUNCAN 40.00 X 0 217359 12389 LEE ANNE EDDY 40.00 X 271891 0 51333 MICHAEL GUTZEIT MD 40.00 X 415980 0 73069 BARBARA JOERS 40.00 X 103870 0 15700 JULIET KERSTEN 40.00 X 0 201424 57975 NANCY KOROM 40.00 X 372098 0 67646 MARK SHIP 40.00 X 295441 0 58338 DONNA JAMIESON 40.00 X 191344 0 44202 TOM LAUSTEN 40.00 X 150248 0 32364 MARY O'CONNER 40.00 X 159446 0 25591 JEFFERY GLASSHEIM MD 40.00 X 289913 0 21503 ANDREW SCHMIDT MD 40.00 X 237260 0 30808 LORI BARBEAU DDS 40.00 X 231864 0 37248 THOMAS NICHOLS MD 40.00 X 206251 0 34086 A CHARLES POST DDS 40.00 X 197942 0 27380 RAMESH SACHDEVA MD 40.00 X 0 378816 58468 JON E VICE - FORMER 0.00 X 0 5795708 39648 3674973 8541295 1163291 114 1 1 0 MEDICAL COLLEGE OF WISCONSIN INC 8701 WATERTOWN PLANK RD MILWAUKEE WI 53226 HEALTHCARE PROF/ ACAD/ADMIN 26189901 MEDICAL COLLEGE OF WI AFFIL HSPTLS 8701 WATERTOWN PLANK RD MILWAUKEE WI 53226 RESIDENT SERVICES 9888914 BLOOD CENTER OF SE WISCONSIN INC 638 N 18TH ST MILWAUKEE WI 532332121 BLOOD PRODUCTS/LAB SERVICES 9463934 THEDA CARE INC 122 E COLLEGE AVE APPLETON WI 549128025 PATIENT HEALTH SRVCS 4316449 FLIGHT FOR LIFE MILWAUKEE 2611 AVIATION RD WAUKESHA WI 53186 AIR TRANSPORT SRVCS 1634400 48 5127015 12926860 1191719 212940 19245594 NET PATIENT SVC REV 621990 517028418 517028418 RENTAL INCOME 531120 5295662 1051525 4244137 SHARED SERVICES 541900 1714249 1714249 524038329 8325562 8325562 75554392 17235 75077658 504352 476734 -487117 -10383 -10383 CAFETERIA 722210 2255595 2255595 PHARMACY SALES TO EMPL 446110 1524996 1524996 REBATES AND DISCOUNTS 900099 1304299 1304299 2762207 2027310 183349 551548 7847097 559446199 523125801 183349 16891455 495578 495578 4241969 4241969 162145806 136756331 25389475 7028216 5980730 1047486 26503160 22265001 4238159 12308380 10228059 2080321 47235034 1256619 45978415 421946 421946 22335112 22335112 12312 12312 4711426 2703482 2007944 876457 876457 19215311 18237575 977736 596551 278897 317654 95323 40393 54930 14730091 14730091 17070336 17070336 37244888 37244888 1779296 20751 1758545 MEDICAL SUPPLIES 58981217 58981217 PURCHASED SERVICES 39281909 39251073 30836 HOSPITAL ASSESSMENT TAX 12593303 12593303 RESIDENT STIPENDS AND B 9352767 9352767 NON-MEDICAL SUPPLIES 3559205 3012153 547052 15441155 14432880 1008275 518256748 428156005 90100743 0 7639515 14715003 2387431 2635976 62158370 58844806 15000 499252 555000 3236907 3260083 5418700 5344745 624020445 219180910 420668064 404839535 227126123 281227397 353344519 382160495 1082493881 1153583040 52623469 59647371 847522 765066 280001195 276090977 54033018 67037932 387505204 403541346 X 566962678 603323347 27873778 32280031 100152221 114438316 694988677 750041694 1082493881 1153583040 X 41189451 13863566 X 0 1 1 X 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 1 175595 156253 114187 217661 0 301025999 13508585 13344633 7310168 850700 319718349 246110966 12400322 48806039 6291328 301025999 294258148 20363545 -54457713 14053014 246110966 0.54100 0.35800 0.10100 0 1 1 460647151 144327495 316319656 6561797 2759156 3802641 145323668 70993539 74330129 11487829 1100720 10387109 404839535 DUE FROM AFFILIATES 27033950 BENEFICIAL INTEREST IN NET ASSETS OF CHILDREN'S HOSP & HEALTH SYSTEM FOUND. 354815314 457 PLAN ASSETS 311231 382160495 RESERVE FOR MEDICAL EDUCATION GRANT SETTLEMENTS 3923015 CAPITAL AND OTHER LEASE OBLIGATIONS 2463547 FAIR VALUE OF INTEREST RATE SWAP AGREEMENTS 18443873 457 PLAN LIABILITY 311231 ACCRUED PENSION 40116067 ESTIMATED THIRD PARTY PAYER SETTLEMENTS 1780199 67037932 559446199 518256748 41189451 3609238 10254328 13863566 55053017 547401830 3609238 -12331150 -8721912 556123742 3322457 3322457 559446199 495573512 0 495573512 22683236 22683236 518256748 PART IV, LINE 1B: CERTAIN EMPLOYEES OF THE ORGANIZATION HAVE SIGNING AUTHORITY FOR THE CHILDREN'S HOSPITAL OF WISCONSIN MEDICAL STAFF FUNDS MONEY MARKET AND CHECKING ACCOUNT. AN EMPLOYEE OF THE ORGANIZATION ALSO PROVIDES ALL MONTHLY ACCOUNTING FUNCTIONS. 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 CHILDREN'S HOSPITAL OF WISCONSIN, INC. INTENDED USES OF THE FUNDS INCLUDE VARIOUS HEALTH-RELATED SERVICES, CAPITAL PROJECTS AND RESEARCH. DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: THE HOSPITAL (CHILDREN'S HOSPITAL OF WISCONSIN, INC.) EVALUATES ITS UNCERTAIN TAX POSITIONS ON AN ANNUAL BASIS, AND THERE HAVE BEEN NO UNCERTAIN TAX POSITONS RECORDED IN 2010 OR 2009. PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -6,718,250 INCREASE IN BENEF. INTEREST IN NET ASSETS OF CHILDREN'S HOSPITAL FOUNDATION 31,146,294 PENSION-RELATED CHANGE OTHER THAN NET PERIODIC PENSION COST -14,173,716 TOTAL PART XI, LINE 8 10,254,328 PART XII, LINE 2D - OTHER ADJUSTMENTS: CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENTS -6,718,250 NET INTEREST COST - FIXED PAYER INTEREST RATE SWAPS -5,175,462 INVESTMENT FEES -421,945 TAX EXPENSE -15,493 TOTAL PART XII, LINE 2D -12,331,150 PART XII, LINE 4B - OTHER ADJUSTMENTS: NET ASSETS RELEASED FROM RESTRICTIONS-CAPITAL ACQUISITIONS 3,322,457 PART XIII, LINE 4B - OTHER ADJUSTMENTS: PAYMENTS TO AFFILIATES 17,070,336 NET INTEREST COST - FIXED PAYER INTEREST RATE SWAPS 5,175,462 INVESTMENT FEES 421,945 TAX EXPENSE 15,493 TOTAL PART XIII, LINE 4B 22,683,236 1 1 X 1 X 1 X 1 1 0 1 1 941479 941479 0.00180 222586033 173340512 49245521 0.09580 223527512 173340512 50187000 0.09760 5640162 22386 5617776 0.01090 29757992 7427498 22330494 0.04340 12527758 6136079 6391679 0.01240 7811906 7811906 0.01520 613937 613937 0.00120 56351755 13585963 42765792 0.08320 279879267 186926475 92952792 0.18080 178750 178750 0.00030 1345207 43738 1301469 0.00250 1264746 300 1264446 0.00240 1390 1390 0.00000 324 324 0.00000 2790417 44038 2746379 0.00520 0 2078686 130000 653248 1184031 -530783 X 1 1 11 1 CHILDREN'S HOSPITAL OF WISCONSIN INC

9000 W WISCONSIN AVE MILWAUKEE WI 53201

X X X X X X 2 CHILDREN'S HOSPITAL OF WI-FOX VALLEY

130 S 2ND STREET NEENAH WI 54956

X X X 3 CHW CLINICS - NEW BERLIN

4855 S MOORELAND ROAD NEW BERLIN WI 53151

X X X X HOSPITAL OUTPATIENT SERVICES 4 CHW CLINICS - GREENWAY

3365 S 103RD ST GREENFIELD WI 53227

X X X X HOSPITAL OUTPATIENT SERVICES 5 CHILDREN'S DENTAL CENTER

1020 N 12TH ST MILWAUKEE WI 53233

X X X HOSPITAL OUTPATIENT SERVICES 6 CHILD PROTECTION CENTER

1020 N 12TH ST MILWAUKEE WI 53233

X X X HOSPITAL OUTPATIENT SERVICES 7 GENETICS CENTER

1092 N 92ND ST WAUWATOSA WI 53226

X X X X HOSPITAL OUTPATIENT SERVICES 8 CHILD DEVELOPMENT CENTER

13800 W NORTH AVE SUITE 120 BROOKFIELD WI 53005

X X X HOSPITAL OUTPATIENT SERVICES 9 CHW CLINICS - KENOSHA

6308 8TH AVE SUITE 3090 KENOSHA WI 53143

X X X HOSPITAL OUTPATIENT SERVICES 10 KENOSHA CHILD ADVOCACY CENTER

6308 8TH AVE SUITE 3090 KENOSHA WI 53143

X X X HOSPITAL OUTPATIENT SERVICES 11 CHW CLINICS - GREEN BAY

555 REDBIRD CIRCLE DE PERE WI 54115

X X HOSPITAL OUTPATIENT SERVICES NA 1 0 0 0 0 0 0 0 0 0 0 0 6 CHILDREN'S HOSPITAL OF WISCONSIN

1020 N 12TH ST 5TH FLOOR MILWAUKEE WI 53233

MENTAL HEALTH OUTPATIENT CLINIC CHW FOX VALLEY BEHAVIORAL HEALTH

1820 N APPLETON RD MENASHA WI 54952

PATIENT CARE SERVICES CHILD ADVOCACY CENTER - FOX VALLEY

325 N COMMERCIAL ST SUITE 400 NEENAH WI 54956

PATIENT CARE SERVICES CHILD ADVOCACY CENTER - RACINE

2405 NORTHWESTERN AVE SUITE 2058 RACINE WI 53404

PATIENT CARE SERVICES CHILD ADVOCACY CENTER - WAUKESHA

101 W BROADWAY 2ND FLOOR WAUKESHA WI 53186

PATIENT CARE SERVICES DOWNTOWN HEALTH CENTER

1020 N 12TH ST MILWAUKEE WI 53233

URBAN HEALTH CENTER PART I, LINE 3C: CHILDREN'S HOSPITAL OF WISCONSIN, INC. ("THE HOSPITAL") USES THE FEDERAL POVERTY GUIDELINES TO DETERMINE ELIGIBILITY. THE HOSPITAL IS DEDICATED TO ENSURING THAT PATIENTS RECEIVE ALL MEDICALLY NECESSARY CARE. IN FURTHERANCE OF THAT OBJECTIVE, THE HOSPITAL MAINTAINS AND IMPLEMENTS VARIOUS POLICIES (INCLUDING A CHARITY CARE POLICY AND SELF-PAY POLICY), PURSUANT TO WHICH THE HOSPITAL PROVIDES DISCOUNTED OR FREE CARE TO PATIENTS WHO ARE UNINSURED OR OTHERWISE UNABLE TO PAY ALL OR A PORTION OF THEIR BILLED CHARGES. THE POLICIES GENERALLY PROVIDE THAT ELIGIBILITY IS DETERMINED BASED ON HOUSEHOLD INCOME, FAMILY SIZE AND AVAILABLE ASSETS, AND SPECIFICALLY INCORPORATES CRITERIA SET FORTH UNDER THE WISCONSIN MEDICAID PROGRAM AND THE FEDERAL POVERTY GUIDELINES. PART I, LINE 6A: CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS"), THE SOLE CORPORATE MEMBER OF THE HOSPITAL, PREPARES A COMMUNITY BENEFIT REPORT ON BEHALF OF THE HOSPITAL AND ITS AFFILIATES. THE REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION AND IS ALSO AVAILABLE ON THE HOSPITAL'S WEB SITE OR UPON REQUEST. PART I, LINE 7: THE WISCONSIN MEDICAID PROGRAM PROVIDES COVERAGE FOR THE VAST MAJORITY OF CHILDREN WHO REQUIRE MEDICAL CARE BUT ARE UNINSURED OR UNDERINSURED. HOSPITAL REPRESENTATIVES WORK EXTENSIVELY WITH PATIENTS' FAMILIES TO HELP THEM UNDERSTAND THE AVAILABILITY OF STATE AID AND TO ASSIST THEM IN BECOMING ENROLLED IN THE PROGRAM THAT PROVIDES THE PATIENT WITH THE GREATEST BENEFIT. FOR THAT REASON, THE AMOUNT OF TRUE "CHARITY CARE" RENDERED BY THE HOSPITAL IS CONSIDERABLY SMALLER THAN LEVELS EXPERIENCED BY COMMUNITY HOSPITALS OR OTHER FACILITIES SERVING THE ADULT POPULATION.PART I, LINE 7, COLUMN (F): BAD DEBT EXPENSE OF $4,218,627 IS INCLUDED IN TOTAL EXPENSES IN PART IX, LINE 25, COLUMN (A), BUT EXCLUDED IN THE CALCULATION OF "PERCENT OF TOTAL EXPENSES" REPORTED IN COLUMN (F). PART II: THE HOSPITAL'S COMMUNITY-BUILDING ACTIVITIES INCLUDE PROGRAMS THAT ADDRESS THE ROOT CAUSES OF HEALTH PROBLEMS FOR CHILDREN, SUCH AS POVERTY AND ENVIRONMENTAL ISSUES. THESE COMMUNITY-BUILDING ACTIVITIES INCLUDE STAFF PARTICIPATION ON COMMUNITY BOARDS, COALITIONS AND/OR COMMITTEES WHICH ASSIST IN IMPROVING THE HEALTH OF THE COMMUNITY. IN ADDITION, THE HOSPITAL HOSTED LISTENING SESSIONS WITH COMMUNITY LEADERS AND ORGANIZERS IN THREE AT-RISK NEIGHBORHOODS TO LEARN MORE ABOUT COMMUNITY NEEDS AND HOW BEST TO ADDRESS THOSE NEEDS. THE HOSPITAL CONDUCTS OR PARTICIPATES IN MANY PROGRAMS THAT HELP COMMUNITY MEMBERS KEEP THEIR CHILDREN AND FAMILIES HEALTHY. EXAMPLES INCLUDE:CHILDREN'S HEALTH ALLIANCE OF WISCONSIN IS A STATEWIDE ORGANIZATION THAT WORKS TO IMPROVE THE HEALTH OF WISCONSIN CHILDREN AND REDUCE DISPARITIES IN AVAILABILITY AND ACCESSIBILITY OF HEALTH CARE SERVICES. THE ALLIANCE BRINGS PEOPLE TOGETHER TO RAISE AWARENESS, INCREASE ACCESS TO QUALITY CARE AND PROMOTE BEST PRACTICES. THE ALLIANCE IS PARTIALLY FUNDED THROUGH A MATERNAL AND CHILD HEALTH, WISCONSIN DEPARTMENT OF HEALTH SERVICES GRANT AND OTHER PUBLIC AND PRIVATE FUNDING. THE ALLIANCE IS FINANCIALLY SUPPORTED BY THE HOSPITAL THROUGH STAFF AND OTHER RESOURCES TO CARRY ON THE ALLIANCE'S PROGRAMS. THE ALLIANCE LEADS AND MANAGES THE FOLLOWING KEY INITIATIVES: ASTHMA, GRIEF AND BEREAVEMENT, INJURY PREVENTION AND CHILD DEATH REVIEW, LEAD POISONING, ORAL HEALTH COALITION, AND REACH OUT AND READ.THE DANIEL M. SOREF FAMILY RESOURCE CENTER LOCATED ON THE FIRST FLOOR OF THE HOSPITAL'S MILWAUKEE CAMPUS OFFERS PARENT-TO-PARENT SUPPORT, INFORMATION, REFERRALS AND HELP CONNECTING TO HOSPITAL AND COMMUNITY RESOURCES. THE CENTER OFFERS SPIRITUAL CARE, THE KATIE BECKETT PROGRAM, PATIENT RELATIONS, INTERPRETERS, FAMILY ACCOMMODATIONS AND THE SOUTHEAST REGIONAL CENTER FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS. THE CENTER HAS FAMILY COMPUTERS, A CONSULT ROOM, FAMILY BUSINESS CENTER AND OTHER RESOURCES FOR FAMILIES. FAMILIES ALSO CAN CHECK OUT ENTERTAINMENT DVDS, VIDEO GAMES, AS WELL AS LAPTOPS FOR INPATIENT USE. STAFF MEMBERS ARE TRAINED TO HELP CHILDREN, YOUNG ADULTS AND THEIR FAMILIES FIND ANSWERS TO QUESTIONS ABOUT LOCAL RESOURCES, SUPPORT GROUPS, FUNDING OPTIONS AND MORE. THE CENTER ALSO HAS A LENDING LIBRARY WITH BOOKS, VIDEOS AND ARTICLES ON A VARIETY OF HEALTH CONDITIONS AND TOPICS.THE INFANT DEATH CENTER ("IDC") IS A STATEWIDE PROGRAM ADMINISTERED THROUGH CHILDREN'S HEALTH ALLIANCE OF WISCONSIN. THE CENTER PROVIDES INFORMATION AND SUPPORT TO WISCONSIN FAMILIES AND OTHERS AFFECTED BY THE SUDDEN AND UNEXPECTED DEATH OF AN INFANT. THE IDC STRIVES TO INCREASE HEALTHY BIRTH OUTCOMES AND REDUCE INFANT DEATHS. THE CENTER WORKS TOGETHER WITH OTHER PROFESSIONALS IN OUTREACH, EDUCATION AND INFANT MORTALITY REVIEW PROGRAMS. IN PARTNERSHIP WITH PUBLIC HEALTH SYSTEMS AND NATIONAL INFANT MORTALITY PROGRAMS, THE IDC MAINTAINS INFORMATION THAT ASSISTS IN THE STUDY AND UNDERSTANDING OF THE CAUSES OF INFANT DEATHS. THE INFORMATION IS USED FOR STATISTICAL REPORTING.THE HOSPITAL'S SPECIAL NEEDS PROGRAM OFFERS COMPREHENSIVE CARE COORDINATION FOR CHILDREN WITH MULTIPLE MEDICAL NEEDS WHO DO NOT HAVE EXISTING CARE COORDINATION SERVICES. THE GOAL IS TO ENSURE FAMILIES HAVE THE BEST POSSIBLE CARE IN AND OUT OF THE HOSPITAL. THE HOSPITAL PARTNERS WITH PATIENTS, FAMILIES, PRIMARY CARE AND OTHER HEALTH CARE PROVIDERS TO IMPROVE CARE COORDINATION. STAFF ALSO WORK WITH FAMILIES TO DEVELOP WRITTEN TRANSITION PLANS BASED ON NEEDS OR ISSUES THAT SHOULD BE ADDRESSED BEFORE A YOUTH IS READY TO TRANSITION TO ADULT CARE.THE HOSPITAL ALSO SUPPORTS THE SOUTHEAST REGIONAL CENTER FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS PROGRAM. IT IS ONE OF FIVE REGIONAL CENTERS DEDICATED TO SUPPORTING FAMILIES WITH CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS AND THE PROVIDERS WHO CARE FOR THEM. IT IS FUNDED THROUGH A TITLE 5 MATERNAL AND CHILD HEALTH BLOCK GRANT, CHILDREN'S HOSPITAL AND CHARITABLE DONATIONS. FAMILIES AND PROVIDERS CAN CALL THE CENTER FOR INFORMATION, REFERRAL AND PROBLEM-SOLVING RELATED TO COMMUNITY AND STATE SERVICES, HEALTH BENEFITS ASSISTANCE, TRANSITION PLANNING AND EMOTIONAL SUPPORT. EACH YEAR THE STAFF OFFERS TRAINING SUCH AS "CARE IN THE COMMUNITY" AS WELL AS OTHER SESSIONS ON YOUTH TRANSITIONS. STAFF ALSO PARTICIPATE IN NUMEROUS COMMUNITY INITIATIVES AND PARTNER WITH AREA PEDIATRICIANS AND OTHER HEALTH CARE PROVIDERS TO INCORPORATE EARLY IDENTIFICATION AND SCREENING METHODS INTO THEIR PRACTICES. THE SOUTHEAST CENTER SERVES EIGHT COUNTIES. THE HOSPITAL ALSO OPERATES A FREE GUARDIANSHIP CLINIC, WHICH PROVIDES PARENTS IN NEED WITH PRO BONO LEGAL SERVICES TO SECURE GUARDIANSHIP WHEN THEIR SPECIAL NEEDS CHILD TURNS 18.FIGHT ASTHMA MILWAUKEE, WHICH IS LED AND SUPPORTED BY MEDICAL STAFF AT THE HOSPITAL, WORKS TO REDUCE AND ELIMINATE DISPARITIES IN ASTHMA CARE AND DEVELOP A SUSTAINABLE STRATEGY FOR ASTHMA CONTROL IN THE COMMUNITY. FIGHT ASTHMA MILWAUKEE PROVIDES COMMUNITY-WIDE ASTHMA EDUCATION FOR PARENTS, CAREGIVERS, HEALTH CARE PROFESSIONALS AND SCHOOL STAFF.IN THE FOX VALLEY, THE HOSPITAL AND THEDA CLARK MEDICAL CENTER PARTNER WITH ROOSEVELT ELEMENTARY SCHOOL TO PROMOTE TO STUDENTS HEALTHY HABITS AND CIVIC RESPONSIBILITY. STAFF MEMBERS FROM BOTH HOSPITALS MENTOR STUDENTS THROUGH THE BACKYARD BUDDIES PROGRAM. THE HOSPITAL ALSO PARTNERS WITH LOCAL ORGANIZATIONS IN THE FOX VALLEY TO IMPROVE THE HEALTH OF THE CHILDREN IN THE COMMUNITY THROUGH NUMEROUS EVENTS SUCH AS A BIKE HELMET SAFETY EVENT AT THE YMCA, HEALTHY KIDS DAY, AND THE APPLETON AREA SCHOOL DISTRICT'S EDUCATION FOR HEALTHY KIDS SUMMER INSTITUTE. EACH SPRING, THE HOSPITAL AND THEDA CLARK MEDICAL CENTER COLLABORATE TO OFFER FREE HOSPITAL TOURS TO FIRST-GRADE STUDENTS FROM LOCAL PUBLIC AND PRIVATE SCHOOLS. STAFF ALSO PROVIDE EDUCATION TO OTHER HEALTH CARE PROVIDERS AND PROFESSIONALS IN THE COMMUNITY ON TOPICS SUCH AS CHILD ABUSE, NEONATAL RESUSCITATION, CHILD AND ADOLESCENT MENTAL HEALTH AND DIABETES. THE HOSPITAL OPERATES CHILD ADVOCACY CENTERS IN MILWAUKEE, RACINE, KENOSHA, WALWORTH COUNTY, CENTRAL WISCONSIN (WAUSAU), THE FOX VALLEY, AND CHIPPEWA VALLEY (EAU CLAIRE). EACH CENTER IS A SAFE PLACE FOR KIDS WHO MAY HAVE BEEN ABUSED OR NEGLECTED. THE CENTERS BRING TOGETHER A TEAM OF SPECIALLY TRAINED PROFESSIONALS WHO EVALUATE AND INVESTIGATE CASES OF CHILD ABUSE, PROVIDE MEDICAL CARE AND HELP CHILDREN AND THEIR FAMILIES TO HEAL. THE CENTERS ARE A COLLABORATION OF THE HOSPITAL AND DOZENS OF LAW ENFORCEMENT, JUDICIAL AND LOCAL AND SOCIAL SERVICE ORGANIZATIONS.VOLUNTEERS FROM THE HOSPITAL ANNUALLY STAFF THE SUMMER CAMP FOR BURN INJURED YOUTH, SPONSORED BY THE WISCONSIN ALLIANCE FOR FIRE SAFETY. THE CAMP IS A STATEWIDE EFFORT TO OFFER A SUMMER CAMPING EXPERIENCE FOR YOUTH WHO HAVE ENDURED SIGNIFICANT BURN INJURIES, PROVIDING THEM AN OPPORTUNITY TO HAVE FUN, MAKE FRIENDS AND IMPROVE SELF-ESTEEM. PART III, LINE 3: THE HOSPITAL ESTIMATED THE AMOUNT OF BAD DEBT EXPENSE (AT COST) ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S CHARITY CARE POLICY BY ANALYZING PAST ACTIVITY FOR ACCOUNTS CLASSIFIED AS BAD DEBT THAT SUBSEQUENTLY QUALIFIED FOR CHARITY CARE WHEN ADDITIONAL ELIGIBILITY INFORMATION WAS RECEIVED. PART III, LINE 4: THE HOSPITAL'S FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE DESCRIBING BAD DEBT EXPENSE. BAD DEBT REPORTED IN PART III, SECTION A IS CALCULATED BASED ON THE HOSPITAL'S OVERALL RATIO OF PATIENT CARE COST TO CHARGES CALCULATED USING THE METHODOLOGY IN WORKSHEET 2 OF SCHEDULE H INSTRUCTIONS. PART III, LINE 8: THE HOSPITAL USED ITS FILED MEDICARE COST REPORT TO OBTAIN THE MEDICARE ALLOWABLE COST REPORTED ON PART III, SECTION B. AS A CHILDREN'S HOSPITAL, THE HOSPITAL HAS A SMALL POPULATION OF MEDICARE PATIENTS AND IS PAID SUBSTANTIALLY LESS THAN COST DUE TO THE REIMBURSEMENT METHODOLOGY USED BY MEDICARE. PART III, LINE 9B: UNDER THE HOSPITAL'S POLICIES AND PROCEDURES, THE HOSPITAL UNDERTAKES MEASURES TO COMMUNICATE WITH THE FAMILIES OF PATIENTS WITH SELF-PAY BALANCES. IN MANY CASES, THE HOSPITAL AND FAMILIES WORK TOGETHER TO OBTAIN COVERAGE THROUGH THE STATE MEDICAID PROGRAM. IN CASES WHERE MEDICAID COVERAGE IS NOT AVAILABLE, THE HOSPITAL SEEKS TO OBTAIN INFORMATION NECESSARY TO DETERMINE THE PATIENT'S ELIGIBILITY FOR FINANCIAL ASSISTANCE UNDER THE HOSPITAL'S CHARITY CARE PROGRAM. ONCE A PATIENT'S ELIGIBILITY FOR FREE OR DISCOUNTED CARE HAS BEEN DETERMINED, THE BALANCE ON THE PATIENT'S ACCOUNT IS ADJUSTED ACCORDINGLY. IN ADDITION, HOSPITAL PERSONNEL WORK CLOSELY WITH FAMILIES TO DETERMINE THEIR ABILITY TO PAY THE ADJUSTED BALANCES; SUCH EFFORTS OFTEN RESULT IN PAYMENT PLANS INTENDED TO PERMIT THE GRADUAL PAYMENT OF AMOUNTS DUE WITHOUT IMPOSING UNDUE FINANCIAL HARDSHIP ON FAMILIES ALREADY DEALING WITH THE CHALLENGES OF CHILDREN'S HEALTH ISSUES. UNFORTUNATELY, THERE REMAIN CIRCUMSTANCES WHERE PATIENTS CANNOT BE DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE DUE TO THE INACCESSIBILITY OF THE FAMILY, OR THE FAMILY'S INABILITY OR REFUSAL TO PROVIDE THE REQUIRED INFORMATION; IN SUCH CASES, THE HOSPITAL FOLLOWS AN ESTABLISHED MULTI-STEP PROCESS IN AN EFFORT TO REACH THE FAMILY AND PROVIDE THEM WITH INFORMATION ABOUT THE AVAILABILITY OF FINANCIAL ASSISTANCE UNDER THE PROGRAM. ACCOUNTS ARE SENT TO COLLECTIONS (AN AFFILIATED ORGANIZATION WITH SUBSTANTIAL EXPERIENCE IN COLLECTION OF PATIENT ACCOUNTS) ONLY AFTER ALL ESTABLISHED STEPS HAVE BEEN UNDERTAKEN, WITHOUT SUCCESS. PART VI, LINE 2: IN ADDITION TO LOCAL LISTENING SESSIONS AND OTHER EFFORTS DESCRIBED WITHIN SCHEDULE H, THE HOSPITAL USES SECONDARY DATA SUCH AS THE WISCONSIN HEALTHIEST PEOPLE 2010 TO ASSESS THE NEEDS OF THE COMMUNITY. THE HOSPITAL IS CURRENTLY WORKING ON THE DEVELOPMENT OF A COMMUNITY NEEDS ASSESSMENT WITH A TEAM OF HEALTH CARE PROVIDERS, COMMUNITY AGENCIES, CLINICS, LOCAL HEALTH DEPARTMENTS AND OTHER PUBLIC HEALTH PROFESSIONALS WHO WILL CONDUCT A COMMUNITY NEEDS ASSESSMENT IN 2012. PART VI, LINE 3: AS INDICATED ABOVE, THE HOSPITAL WORKS CLOSELY WITH PATIENTS' FAMILIES TO HELP THEM UNDERSTAND AND ENROLL IN MEDICAL ASSISTANCE PROGRAMS AVAILABLE THROUGH THE STATE OF WISCONSIN, AND WHERE APPROPRIATE, FEDERAL PROGRAMS. WHERE SUCH PROGRAMS ARE NOT AVAILABLE, HOWEVER, PATIENTS MAY BE ELIGIBLE FOR FREE OR DISCOUNTED CARE UNDER THE HOSPITAL'S ESTABLISHED POLICIES AND PROCEDURES. THE AVAILABILITY OF FINANCIAL ASSISTANCE IS PUBLICIZED THROUGH VARIOUS MEASURES, INCLUDING INFORMATION ON THE HOSPITAL'S WEBSITE AND WRITTEN BROCHURES OR OTHER MATERIALS PROVIDED TO PATIENTS' FAMILIES. THE MOST SIGNIFICANT EDUCATION, HOWEVER, OCCURS IN DIRECT DIALOGUE BETWEEN PATIENT FAMILIES AND THE HOSPITAL'S TRAINED FINANCIAL SERVICES COUNSELORS AND SOCIAL WORKERS. THE HOSPITAL MAKES EXTENSIVE EFFORTS TO PROVIDE FACE-TO-FACE DIALOGUE, AS WELL AS COMMUNICATION VIA TELEPHONE, E-MAIL AND OTHER MEANS, AS NECESSARY TO ENSURE THAT FAMILIES ARE PROVIDED WITH SUFFICIENT INFORMATION REGARDING ALTERNATIVES FOR OBTAINING FREE OR DISCOUNTED CARE, AS WELL AS THE BILLING AND COLLECTION PROCESS GENERALLY. THE COMMUNICATION PROCESS IS SUPPORTED BY INTERPRETER SERVICES AS NEEDED. PART VI, LINE 4: THE HOSPITAL PROVIDES CARE TO CHILDREN FROM URBAN, RURAL, AND SUBURBAN AREAS, REGARDLESS OF RACE, GENDER, ETHNICITY, INCOME, DISABILITY, OR COUNTRY OF ORIGIN. THE HOSPITAL PROVIDES ACUTE LEVEL SERVICES, AS WELL AS EMERGENCY AND SPECIALTY CARE TO CHILDREN FROM WISCONSIN, UPPER PENINSULA OF MICHIGAN, NORTHERN ILLINOIS AND THROUGHOUT THE UNITED STATES. APPROXIMATELY 49 PERCENT OF GROSS CHARGES FOR PATIENT SERVICES WERE GENERATED FROM SERVICES TO MEDICAID BENEFICIARIES IN 2010. PART VI, LINE 6: THE HOSPITAL PROMOTES THE HEALTH AND SAFETY OF CHILDREN LOCATED THROUGHOUT ITS SERVICE AREA. THE HOSPITAL OPERATES AN EMERGENCY ROOM OPEN TO ALL PERSONS, WITHOUT REGARD TO THE ABILITY TO PAY. THE HOSPITAL'S BOARD OF DIRECTORS CONSISTS PRIMARILY OF INDIVIDUALS REPRESENTING THE COMMUNITY. THE HOSPITAL MAINTAINS AN OPEN MEDICAL STAFF, WITH MEMBERSHIP AND PRIVILEGES AVAILABLE TO ALL QUALIFIED PHYSICIANS AND HEALTHCARE PROFESSIONALS, AS SET FORTH IN THE MEDICAL STAFF BYLAWS, RULES AND REGULATIONS. THE HOSPITAL USES ANY SURPLUS FUNDS TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND OR IMPROVE ITS FACILITIES, AND ADVANCE ITS MEDICAL TRAINING, EDUCATION AND RESEARCH PROGRAMS. IN THESE AND OTHER RESPECTS, THE HOSPITAL IS ORGANIZED AND OPERATED IN A MANNER THAT PROMOTES THE HEALTH OF THE COMMUNITY AND THEREFORE FULFILLS CHARITABLE PURPOSES WITHIN THE MEANING OF INTERNAL REVENUE CODE SECTION 501(C)(3). THE HOSPITAL OFFERS SPECIALTY CLINICS THAT ARE COMFORTABLE AND ACCESSIBLE TO FAMILIES. IN MILWAUKEE, THE HOSPITAL OFFERS CLINICS IN THE CENTRAL, DOWNTOWN AND SOUTHWEST PART OF THE CITY. FAMILIES ALSO MAY ACCESS SERVICES IN THE FOX VALLEY, GREEN BAY AND KENOSHA AREAS. IN 2009, THE HOSPITAL OPENED A MULTISPECIALTY AMBULATORY CENTER IN NEW BERLIN, WIS., TO PROVIDE FAMILIES WITH EASY ACCESS TO CARE. THE HOSPITAL FUNDS SCHOOL-BASED HEALTH CENTERS IN MILWAUKEE SCHOOLS AND AT A SITE LOCATED IN THE NEXT DOOR FOUNDATION. 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 2010, THERE WERE 15,750 SCHOOL-BASED NURSE ENCOUNTERS AND 5,071 PHYSICIAN OFFICE VISITS AT THE NEXT DOOR FOUNDATION SITE.THE HOSPITAL, IN COLLABORATION WITH THE MEDICAL COLLEGE OF WISCONSIN, SPONSORS THE DOWNTOWN HEALTH CENTER. LOCATED IN DOWNTOWN MILWAUKEE, THE MISSION OF THIS CLINIC IS TO IMPROVE HEALTH AND ADVANCE HEALTH EQUITY FOR THE MOST VULNERABLE CHILDREN IN MILWAUKEE THROUGH AN ACADEMIC PRIMARY CARE MEDICAL HOME. ON-SITE SERVICES INCLUDE ACUTE AND CHRONIC CARE, WELL-CHILD EXAMINATIONS, LABORATORY STUDIES, AND VISION AND HEARING SCREENINGS. CRIB, CAR SEAT AND BIKE HELMET DISTRIBUTION AND FITTINGS, SAFE-SLEEPING TECHNIQUES, AND GUN-LOCK EDUCATION, ARE OTHER SPECIAL CLINIC ACTIVITIES THAT ARE AVAILABLE AT THIS SITE, MOSTLY FREE OF CHARGE. APPROXIMATELY 7,200 CHILDREN, INCLUDING 500 CHILDREN IN FOSTER CARE, ARE SEEN ANNUALLY AT THE CENTER, AND 92 PERCENT OF THEM ARE INSURED BY MEDICAID/BADGERCARE PLUS. ADOLESCENTS HAVE ACCESS TO SOCIAL SERVICES, CONTRACEPTIVE MANAGEMENT, FAMILY PLANNING, AND ALCOHOL AND DRUG ABUSE COUNSELING SERVICES. IN ADDITION, CHILDREN'S HOSPITAL PROVIDES SPECIALTY CARE SERVICES INCLUDING DENTAL, PSYCHOLOGICAL AND CHILD PROTECTIVE SERVICES AT THIS DOWNTOWN LOCATION.THE HOSPITAL FUNDS CHILDREN'S HEALTH EDUCATION CENTER ("CHEC"), WHICH SEEKS TO EDUCATE THE PUBLIC REGARDING A WIDE RANGE OF ISSUES IMPACTING THE HEALTH AND SAFETY OF CHILDREN. THE CENTER OFFERS RESOURCES AND PROGRAMS FOR CHILDREN, PARENTS, TEACHERS, AND CAREGIVERS TO HELP KEEP WISCONSIN'S CHILDREN HEALTHY AND SAFE. BLUEKIDS.ORG E-LEARNING PROGRAMS, OFFERED THROUGH CHEC, ARE A RESOURCE FOR TEACHERS TO USE IN THEIR CLASSROOMS TO DELIVER AN OUTCOMES-BASED HEALTH CURRICULUM TO STUDENTS IN GRADE K5-8. CHEC'S INJURY PREVENTION TEAM OFFERS COMMUNITY-BASED EDUCATIONAL EVENTS INCLUDING BIKE HELMET FITTINGS AND CAR SEAT CHECKS, AND DELIVERS IMPORTANT FIRE PROTECTION AND PEDESTRIAN SAFETY EDUCATION THROUGHOUT WISCONSIN.THE HOSPITAL'S CAR SEAT CLINIC IS A COLLABORATION BETWEEN THE HOSPITAL, CHEC, SAFE KIDS WISCONSIN AND SAFE KIDS SOUTHEAST WISCONSIN TO OFFER CAR SEAT CLINICS IN TWO LOCATIONS NEAR THE MILWAUKEE HOSPITAL CAMPUS. TRAINED CHILD PASSENGER SAFETY SPECIALISTS MAKE CERTAIN THAT INFANT, TODDLER CAR SEATS AND/OR BOOSTER SEATS ARE INSTALLED CORRECTLY AND THAT THEY ARE APPROPRIATE FOR THE AGE AND SIZE OF THE CHILD USING THEM. IN SOME CASES, THE PROGRAM ALSO PROVIDES LOW-COST OR FREE CAR AND/OR BOOSTER SEATS FOR FAMILIES IN NEED.THE WISCONSIN POISON CENTER, WHICH IS STAFFED BY REGISTERED NURSES 24 HOURS A DAY, 365 DAYS A YEAR, PROVIDES IMMEDIATE AND AUTHORITATIVE PHONE CONSULTATION IN CASES OF ACCIDENTAL OR INTENTIONAL POISONING IN ADULTS AND CHILDREN. THE CENTER HAS A VARIETY OF PROFESSIONAL AND COMMUNITY EDUCATION PROGRAMS ALERTING PEOPLE TO SPECIFIC TOXIC DANGERS. THESE INCLUDE HOSPITAL GRAND ROUNDS LECTURES FOR PHYSICIANS, TRAINING FOR EMERGENCY MEDICAL TECHNICIANS, BABY SITTER WORKSHOPS, AND PRESCHOOL POISON PREVENTION EDUCATION. THE POISON CENTER ALSO TRIAGES CALLS FOR MPOWER, AN ALCOHOL AND DRUG CRISIS LINE FOR TEENS. PROJECT ADAM (AUTOMATIC DEFIBRILLATORS IN ADAM'S MEMORY) IS COMMITTED TO MAKING AUTOMATED EXTERNAL DEFIBRILLATORS UNIVERSALLY AVAILABLE TO ALL CHILDREN AND ADOLESCENTS BY BEING A NATIONAL RESOURCE FOR IMPLEMENTING PEDIATRIC PUBLIC ACCESS DEFIBRILLATION PROGRAMS IN SCHOOLS. IT ALSO IS WORKING TOWARD ERADICATING SUDDEN CARDIAC DEATH IN CHILDREN THROUGH EDUCATION AND PREVENTION INITIATIVES. IN 2010, THE HOSPITAL LAUNCHED A MULTI-YEAR, SYSTEM-WIDE EFFORT TO INCREASE IMMUNIZATION RATES AMONG CHILDREN. THIS INITIATIVE IS KEY TO ACHIEVING THE HEALTH SYSTEM'S VISION OF HELPING WISCONSIN'S CHILDREN TO BE THE HEALTHIEST IN THE NATION. AS PART OF THE INITIATIVE: -THE HOSPITAL HAS PARTNERED WITH THE MILWAUKEE HEALTH DEPARTMENT AND COMMUNITY ORGANIZATIONS TO SPREAD THE WORD THAT VACCINES ARE SAFE AND NECESSARY. -HEALTH CARE PROVIDERS DISCUSS THE IMPORTANCE AND SAFETY OF IMMUNIZATIONS WITH PARENTS DURING VISITS TO OUR HOSPITAL AND CLINICS. -AT EACH VISIT, HEALTH CARE PROVIDERS USE THE WISCONSIN IMMUNIZATION REGISTRY ("WIR") TO CHECK THE IMMUNIZATION STATUS OF PATIENTS YOUNGER THAN 25 MONTHS AND UPDATE INFORMATION IN THE WIR DATABASE, IF NEEDED. -IF A CHILD IS NOT UP TO DATE ON IMMUNIZATIONS, PARENTS AND STAFF PARTNER TO IDENTIFY WHERE THE RECOMMENDED IMMUNIZATIONS CAN BE ADMINISTERED. -IF NECESSARY, HOSPITAL STAFF HELP CONNECT PARENTS WITH A "MEDICAL HOME," A PLACE WHERE CHILDREN CAN RECEIVE PRIMARY CARE ON A REGULAR BASIS. PART VI, LINE 7: THE HOSPITAL IS PART OF AN AFFILIATED GROUP OF ORGANIZATIONS UNDER THE CONTROL OF CHHS, WHICH PROVIDES VARIOUS CENTRALIZED ADMINISTRATIVE AND SUPPORTING SERVICES FOR THE HOSPITAL AND ITS AFFILIATES. AMONG THE AFFILIATED ENTITIES, THE HOSPITAL AND CERTAIN OTHER ENTITIES (INCLUDING CHILDREN'S MEDICAL GROUP, INC. AND CHILDREN'S PHYSICIAN GROUP, P.C.) DIRECTLY PROVIDE INSTITUTIONAL AND PROFESSIONAL PEDIATRIC HEALTHCARE SERVICES IN A VARIETY OF ACCESSIBLE LOCATIONS THROUGHOUT WISCONSIN AND NORTHERN ILLINOIS. ANOTHER HOSPITAL AFFILIATE IS CHILDREN'S SERVICE SOCIETY OF WISCONSIN ("CSSW"). THIS SOCIAL SERVICE ORGANIZATION ADDRESSES THE CHALLENGES FACED BY CHILDREN, WHICH OFTEN DIRECTLY IMPACT THEIR PHYSICAL AND MENTAL HEALTH AND WELLBEING.CSSW OFFERS CHILD WELFARE SERVICES IN FOUR CORE AREAS (PUBLIC CHILD WELFARE, CHILD AND FAMILY COUNSELING, OUT-OF-HOME CARE AND PREVENTION SERVICES) FROM LOCATIONS THROUGHOUT WISCONSIN. SERVICES INCLUDE: -LOCATING LOVING, STABLE HOMES FOR CHILDREN IN NEED OF A FAMILY THROUGH FOSTER CARE AND ADOPTION. -REDUCING STRESS AND CONFLICT, ENHANCING PARENTING SKILLS AND STRENGTHENING FAMILY TIES THROUGH COUNSELING. -PROVIDING SERVICES TO CHILDREN IN OUT-OF-HOME CARE, ADVOCATING FOR THEIR SAFETY, WELL-BEING AND TIMELY REUNIFICATION WITH BIRTHPARENTS WHENEVER POSSIBLE. -OFFERING FREE, CONFIDENTIAL AND SUPPORTIVE GUIDANCE TO HELP BIRTHPARENTS DEALING WITH AN UNPLANNED PREGNANCY. -PROVIDING INTENSIVE IN-HOME SERVICES TO KEEP CHILDREN SAFE IN THEIR HOMES AND PREVENT OUT-OF-HOME PLACEMENT. -ASSISTING YOUNG ADULTS TRANSITIONING OUT OF FOSTER CARE BY GIVING THEM THE SKILLS, TRAINING, GUIDANCE AND SUPPORT ENABLING THEM TO MAKE IT ON THEIR OWN. -PROVIDING PARENTS WITH SUPPORT AND GUIDANCE TO HELP THEM BE THE BEST PARENTS THEY CAN BE, INCLUDING: -ONGOING REASSESSMENT OF CHILD SAFETY; -FAMILY ASSESSMENT; -DEVELOPMENT OF CASE PLANS; -COORDINATION OF SERVICE; -IMPLEMENTATION OF SAFETY SERVICES THAT ENSURE A FAMILY CAN STAY TOGETHER. CHHS HAS TWO KEY PROGRAMS TO PROMOTE CUTTING EDGE, HIGH QUALITY CARE. CHILDREN'S RESEARCH INSTITUTE CARRIES ON RESEARCH INITIATIVES AIMED AT IMPROVING THE DIAGNOSIS AND TREATMENT OF PEDIATRIC HEALTH CONDITIONS, AND NATIONAL OUTCOMES CENTER GATHERS AND PUBLICIZES DATA TO ASSIST PEDIATRIC HEALTHCARE PROVIDERS IN IDENTIFYING THE MOST EFFECTIVE TREATMENT METHODS. THESE AFFILIATED PROGRAMS SEEK TO ENSURE THAT CHILDREN HAVE ACCESS TO HIGH-QUALITY HEALTH AND SOCIAL SERVICES.PART VI, LINE 7: CHHS, THE SOLE CORPORATE MEMBER OF THE HOSPITAL, PREPARES A COMMUNITY BENEFIT REPORT ON BEHALF OF THE HOSPITAL AND ITS AFFILIATES. THE REPORT IS FILED WITH THE WISCONSIN HOSPITAL ASSOCIATION AND IS ALSO AVAILABLE ON THE SYSTEM'S WEB SITE OR UPON REQUEST. 1 MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK ROAD MILWAUKEE WI 53226 390806261 501(C)(3) 4878 ADDRESSING ASTHMA FROM A PUBLIC HEALTH PERSPECTIVE ADAMS COUNTY PUBLIC HEALTH DEPARTMENT 108 E NORTH STREET FRIENDSHIP WI 53934 396005665 ADAMS COUNTY 5000 DENTAL SEALANT EXPANSION GRANT JANESVILLE SCHOOL DISTRICT 2921 MOHICAN ROAD JANESVILLE WI 535452285 396002726 501(C)(3) 14303 DENTAL SEALANT EXPANSION GRANT JUNEAU COUNTY HEALTH DEPARTMENT 220 E STATE STREET MAUSTON WI 53948 396005706 JUNEAU COUNTY 11689 DENTAL SEALANT EXPANSION GRANT KENOSHA COUNTY DIVISION OF HEALTH 8600 SHERIDAN ROAD 600 KENOSHA WI 53143 396005707 KENOSHA COUNTY 23045 DENTAL SEALANT EXPANSION GRANT MERITER FOUNDATION 202 S PARK STREET MADISON WI 53715 237098688 501(C)(3) 5000 DENTAL SEALANT EXPANSION GRANT NEENAH MENASHA DENTAL CLINIC INC 316 E 20TH STREET KAUKAUNA WI 54130 391471332 501(C)(3) 11204 DENTAL SEALANT EXPANSION GRANT PORTAGE COUNTY HEALTH & HUMAN SERVICES 817 WHITING AVENUE STEVENS POINT WI 54481 396005731 PORTAGE COUNTY 10000 DENTAL SEALANT EXPANSION GRANT SCHOOL DISTRICT OF SUPERIOR PO BOX 146 TWO HARBORS MN 55616 396004736 SCHOOL DISTRICT 10463 DENTAL SEALANT EXPANSION GRANT WALWORTH COUNTY HEALTH & HUMAN SERVICES W4051 COUNTY ROAD NN ELKHORN WI 53121 396005752 WALWORTH COUNTY 9621 DENTAL SEALANT EXPANSION GRANT BAYFIELD COUNTY PUBLIC HEALTH DEPARTMENT 117 E 5TH STREET BAYFIELD WI 54891 396005670 BAYFIELD COUNTY 5000 DENTAL SEALANT GRANT BROWN COUNTY HEALTH DEPARTMENT 610 SOUTH BROADWAY GREEN BAY WI 54305 396005671 BROWN COUNTY 64371 DENTAL SEALANT GRANT COLUMBIA ST MARY'S FOUNDATION 2320 N LAKE DRIVE MILWAUKEE WI 53211 391494981 501(C)(3) 19893 DENTAL SEALANT GRANT COLUMBIA ST MARY'S MADRE ANGEAL 1730 S 13TH STREET MILWAUKEE WI 53204 391494981 501(C)(3) 45673 DENTAL SEALANT GRAMT PRICE COUNTY HEALTH DEPARTMENT 104 S EYDER AVENUE PHILLIPS WI 54555 396005733 PRICE COUNTY 22075 DENTAL SEALANT GRANT SAUK COUNTY HEALTH DEPARTMENT 505 BROADWAY 372 BARABOO WI 53913 396005740 SAUK COUNTY 27136 DENTAL SEALANT GRANT VILAS COUNTY PUBLIC HEALTH 330 COURT STREET EAGLE RIVER WI 54521 396005751 VILAS COUNTY 15000 DENTAL SEALANT GRANT WAUSHERA COUNTY HEALTH DEPARTMENT PO BOX 837 WAUTOMA WI 54982 396005759 WAUSHERA COUNTY 6918 DENTAL SEALANT GRANT WOOD COUNTY HEALTH DEPARTMENT 400 MARKET STREET WISCONSIN RAPIDS WI 54494 396005763 WOOD COUNTY 10000 DENTAL SEALANT GRANT JEFFERSON COUNTY PUBLIC HEALTH DEPARTMENT N3995 ANNEX ROAD JEFFERSON WI 53549 396005705 JEFFERSON COUNTY 6290 MCH BLOCK GRANT - CHILDREN WITH SPECIAL NEEDS KENOSHA COUNTY DIVISION OF HEALTH 8600 SHERIDAN ROAD 600 KENOSHA WI 53143 396005707 KENOSHA COUNTY 7400 MCH BLOCK GRANT - CHILDREN WITH SPECIAL NEEDS SET MINISTRY 2977 N 50TH STREET MILWAUKEE WI 53210 391618277 501(C)(3) 15700 MCH BLOCK GRANT - CHILDREN WITH SPECIAL NEEDS UNITED CEREBRAL PALSY 7519 W OKLAHOMA AVENUE MILWAUKEE WI 53219 391143353 501(C)(3) 36133 MCH BLOCK GRANT - CHILDREN WITH SPECIAL NEEDS MARSHFIELD CLINIC 1000 NORTH OAK AVENUE MARSHFIELD WI 54449 390452970 501(C)(3) 25121 STATE OF WI - GENETICS SYSTEM GRANT MEDICAL COLLEGE OF WISCONSIN 8701 WATERTOWN PLANK ROAD MILWAUKEE WI 53226 390806261 501(C)(3) 14165 STATE OF WI - GENETICS SYSTEM GRANT UNIVERSITY OF WISCONSIN - MADISON DRAWER 538 MILWAUKEE WI 53278 396006492 501(C)(3) 69500 STATE OF WI - GENETICS SYSTEM GRANT 26 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: MONITORING PROCEDURES - THE ORGANIZATION RECEIVES GRANT FUNDING FROM VARIOUS STATE AND FEDERAL AGENCIES. SOME OF THE GRANT AWARDS ARE SUB-AWARDED TO OTHER AGENCIES BASED ON THE REQUIREMENTS OF THE INDIVIDUAL GRANT AGREEMENTS. IN ORDER TO MONITOR THE USE OF THE FUNDS, THE ORGANIZATION ENTERS INTO SIGNED AGREEMENTS WITH THE SUB-GRANTEE AGENCIES TO OUTLINE THE TERMS OF THE ARRANGEMENTS INCLUDING THE PROPER USE OF FUNDS. THESE AGREEMENTS REQUIRE AGENCIES TO PROVIDE CERTIFICATIONS OF EXPENSES SUBMITTED FOR REIMBURSEMENT ALONG WITH DESCRIPTIONS OF THE ACTUAL EXPENSES INCURRED COMPARED TO THE BUDGETED AWARD TOTAL. EACH AWARD IS MONITORED BY A DESIGNATED EMPLOYEE OF THE ORGANIZATION WHO VERIFIES THAT ALL SERVICES ARE PROVIDED ACCORDING TO THE CONTRACT, APPROVES PAYMENTS TO THE AGENCY, AND ENSURES THAT THE AWARD OBJECTIVES ARE MET. IN SOME CASES, THE ORGANIZATION REQUIRES THE AGENCY TO SUBMIT A COPY OF ITS ANNUAL OMB 133 AUDIT ALONG WITH ANY RELEVANT AUDIT FINDINGS. 1 X X X X X X 1 1 0 0 0 0 0 1 0 MARGARET TROY 0 696337 0 238920 0 62498 0 213436 0 33569 0 1244760 0 0 CINTHIA S CHRISTENSEN 350953 0 111248 0 54224 0 48174 0 34556 0 599155 0 31657 0 TIMOTHY L BIRKENSTOCK 0 413954 0 124887 0 58116 0 52773 0 28718 0 678448 0 20063 SHEILA REYNOLDS 0 234291 0 80785 0 38200 0 35168 0 29149 0 417593 0 9703 LAWRENCE DUNCAN 0 105794 0 52668 0 58897 0 0 0 12389 0 229748 0 9361 LEE ANNE EDDY 190049 0 53726 0 28116 0 33932 0 17401 0 323224 0 9421 0 MICHAEL GUTZEIT MD 278910 0 79359 0 57711 0 42983 0 30086 0 489049 0 12402 0 JULIET KERSTEN 0 152005 0 39319 0 10100 0 26735 0 31240 0 259399 0 7380 NANCY KOROM 263553 0 78965 0 29580 0 38480 0 29166 0 439744 0 6784 0 MARK SHIP 209391 0 57200 0 28850 0 29624 0 28714 0 353779 0 16160 0 DONNA JAMIESON 165531 0 25000 0 813 0 15739 0 28463 0 235546 0 0 0 TOM LAUSTEN 148872 0 0 0 1376 0 10676 0 21688 0 182612 0 0 0 MARY O'CONNER 147064 0 0 0 12382 0 14284 0 11307 0 185037 0 0 0 JEFFERY GLASSHEIM MD 257038 0 0 0 32875 0 0 0 21503 0 311416 0 0 0 ANDREW SCHMIDT MD 229177 0 0 0 8083 0 7268 0 23540 0 268068 0 0 0 LORI BARBEAU DDS 231128 0 0 0 736 0 15231 0 22017 0 269112 0 0 0 THOMAS NICHOLS MD 185035 0 0 0 21216 0 13558 0 20528 0 240337 0 0 0 A CHARLES POST DDS 195223 0 0 0 2719 0 17667 0 9713 0 225322 0 0 0 RAMESH SACHDEVA MD 0 285632 0 86213 0 6971 0 29577 0 28891 0 437284 0 5274 JON E VICE - FORMER 0 647628 0 0 0 5148080 0 0 0 39648 0 5835356 0 4895003 PART I, LINES 4A-B UNTIL JANUARY 2009, JON VICE SERVED AS PRESIDENT/CEO OF CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS"), WHICH IS THE CORPORATE MEMBER OF CHW. BY VIRTUE OF THAT ROLE, MR. VICE ALSO SERVED AS A DIRECTOR AND PRESIDENT OF CHW. IN JANUARY 2009, MR. VICE RETIRED AFTER 30 YEARS OF SERVICE WITH CHHS AND ITS AFFILIATES. CHHS PAID CERTAIN AMOUNTS AS SEVERANCE OR EARLY RETIREMENT INCOME TO MR. VICE, WHO SERVED AS PRESIDENT/CEO THROUGH JANUARY 2009. THESE AMOUNTS WERE PAID PURSUANT TO A WRITTEN AGREEMENT ENTERED INTO IN MAY 2008. CASH PAYMENTS MADE TO MR. VICE IN 2010 TOTALED $650,638. HOWEVER, BECAUSE AMOUNTS PAYABLE UNDER THE ARRANGEMENT WERE DEEMED TO HAVE VESTED IN 2010, THE PRESENT VALUE OF PAYMENTS TO BE MADE IN FUTURE YEARS (BASED ON ACTUARIAL ESTIMATES) WAS REPORTED AS TAXABLE INCOME FOR 2010 ACCORDINGLY. PART I, LINE 4B: IN 2010, THERE WAS A CHHS FLEXIBLE BENEFIT PLAN IN PLACE WHICH WAS A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN (457(F) PLAN). THE CORPORATION CONTRIBUTES 7% OF EACH PARTICIPATING EXECUTIVE'S SALARY. THE AMOUNTS OF EMPLOYER CONTRIBUTIONS TO THIS PLAN FOR PARTICIPATING EXECUTIVES IN 2010 WERE AS FOLLOWS: T. BIRKENSTOCK $30,723; M. TROY $50,820; L. EDDY $13,432; M. GUTZEIT, M.D. $20,933; N. KOROM $18,730; R. SACHDEVA, M.D. $20,251; M. SHIP $14,924; C. CHRISTENSEN $26,124; J. KERSTEN $11,028; S. REYNOLDS $18,018. AFTER A VESTING PERIOD, PARTICIPANTS MAY ELECT TO WITHDRAW AMOUNTS PREVIOUSLY CONTRIBUTED AND REPORTED. AMOUNTS WITHDRAWN BY PARTICIPANTS IN 2010 WERE: T. BIRKENSTOCK $20,063; L. DUNCAN $9,361; L. EDDY $9,421; M. GUTZEIT, M.D. $12,402; N. KOROM $6,784; R. SACHDEVA, M.D. $5,274; C. CHRISTENSEN $31,657; M. SHIP $16,160; J. KERSTEN $7,380; S. REYNOLDS $9,703. CHHS HAS REPORTED ADDITIONAL AMOUNTS SET ASIDE FOR A NONQUALIFIED RETIREMENT PLAN ON BEHALF OF ITS PRESIDENT & CEO. THE AMOUNT SET ASIDE IN 2010 WAS $152,816. 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 IN THE EXECUTIVE'S AREA OF RESPONSIBILITY, AS WELL AS ACHIEVEMENT OF OVERALL STRATEGIC OBJECTIVES OF CHHS AND ITS AFFILIATES. SUPPLEMENTAL INFORMATION PART III FORM 990, PART VII, COLUMN E & SCHEDULE J, PART II: SALARIES PAID BY RELATED ORGANIZATIONS: 1. MARGARET TROY, DIRECTOR & PRESIDENT OF CHW AND PRESIDENT & CEO OF CHHS - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. SERVICES AS A MEMBER OF THE BOARD OF DIRECTORS OF CHW WERE PROVIDED ON A PART-TIME VOLUNTARY BASIS. 2. TIMOTHY L. BIRKENSTOCK, TREASURER OF CHW AND TREASURER & CFO OF CHHS - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. 3. SHEILA REYNOLDS, SECRETARY OF CHW AND CORPORATE VICE PRESIDENT & GENERAL COUNSEL OF CHHS - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. 4. LAWRENCE DUNCAN, VICE PRESIDENT OF REGIONAL SERVICES OF CHHS THROUGH JUNE 2010 - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. 5. JULIET KERSTEN, VICE PRESIDENT OF REGIONAL SERVICES OF CHHS BEGINNING JUNE 2010 - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. 6. RAMESH SACHDEVA, M.D., CORPORATE VP AND CHIEF QUALITY OFFICER OF CHHS - 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 CHHS AND ITS AFFILIATES. THESE AMOUNTS WERE PAID BY CHHS. 7. JON E. VICE, FORMER DIRECTOR & PRESIDENT OF CHW AND FORMER PRESIDENT & CEO OF CHHS - REPORTABLE COMPENSATION FROM RELATED ORGANIZATIONS AND OTHER COMPENSATION LISTED IN PART VII AND SCHEDULE J WERE PAID BY CHHS AS DESCRIBED ABOVE. WI HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BCS9 2008-07-29 152300000 SEE PART V 0 0 0 WI HEALTH & EDUCATIONAL FACILITIES AUTHORITY 391337855 97710BCC4 2008-06-25 100771610 SEE PART V 0 0 0 152300953 1000301 2075652 2009 1 0 0 1 113903904 771610 13132293 2009 1 0 0 1 0 1 1 0 1 0.00200 0.00100 0.00300 1 0 0 1 0 1 0.00000 0.00000 0.00000 1 0 0 0 0 0 1 0 0 0 0 0 1 SCHEDULE K SUPPLENTAL INFORMATION SCHEDULE K, PART I, LINE A, DESCRIPTION OF PURPOSE, WHEFA SERIES 2008B: - $49,225,000 WAS ISSUED TO REFUND SERIES 2007-3 BONDS. THE 2007-3 BONDS WERE ISSUED NOVEMBER 20, 2007 TO REFUND A PORTION ($47,110,000) OF THE WHEFA SERIES 1998 BONDS. THE 1998 BONDS WERE ISSUED JUNE 2, 1998. - $100,000,000 WAS ISSUED TO REFUND SERIES 2004B BONDS. THE 2004B BONDS WERE ISSUED MAY 6, 2004 TO CONSTRUCT AND EQUIP CERTAIN HEALTH CARE FACILITIES (CORPORATE CENTER, PARKING STRUCTURE, TUNNEL, UTILITIES, AND NEW PATIENT TOWER) AND TO PAY ISSUANCE COSTS INCLUDING THE BOND INSURANCE POLICY PREMIUM. - $2,060,980 WAS ISSUED TO CONSTRUCT, RENOVATE, AND EQUIP CERTAIN HEALTH CARE FACILITIES (NEW PATIENT TOWER). - $1,014,020 WAS ISSUED TO PAY 2008B BOND ISSUE COSTS. - TOTAL ISSUE FROM 2008B BONDS = $152,300,000 SCHEDULE K, PART I, LINE B, DESCRIPTION OF PURPOSE, WHEFA SERIES 2008A: - $100,000,000 WAS ISSUED TO REFUND SERIES 2007-1 AND 2007-2 BONDS. THE 2007-1 AND 2007-2 BONDS WERE ISSUED NOVEMBER 20, 2007 TO CONSTRUCT, RENOVATE, AND EQUIP CERTAIN HEALTH CARE FACILITIES (NEW PATIENT TOWER) AND TO PAY ISSUANCE COSTS INCLUDING THE BOND INSURANCE POLICY PREMIUM. - $771,610 WAS ISSUED TO PAY 2008A BOND ISSUE COSTS. - TOTAL ISSUE FROM 2008A BONDS = $100,771,610 SCHEDULE K, PART III, COLUMN B, LINE 3A: THE ORGANIZATION HAS DETERMINED BASED ON A LEGAL REVIEW THAT A MANAGEMENT CONTRACT WITH RESPECT TO THE PROPERTY FINANCED BY THE BOND ISSUE LISTED IN COLUMN B DOES NOT RESULT IN PRIVATE BUSINESS USE. SCHEDULE K, ADDITIONAL INFORMATION: THE ORGANIZATION HAS $22,890,000 OF WHEFA SERIES 1998 BONDS OUTSTANDING AS OF DECEMBER 31, 2010 WHICH ARE NOT INCLUDED ON SCHEDULE K PART I AS THEY WERE ISSUED PRIOR TO DECEMBER 31, 2002. UNIVERSITY OF WI-MILWAUKEE DIRECTOR(D GILBERT) 169897 MR. GILBERT IS PRESIDENT OF THE UNIVERSITY OF WISCONSIN-MILWAUKEE FOUNDATION, WHICH IS PART OF THE UNIVERSITY OF WISCONSIN-MILWAUKEE SYSTEM. THE ORGANIZATION PAID $169,897 TO THE UNIVERSITY OF WISCONSIN-MILWAUKEE FOUNDATION FOR EDUCATIONAL PROGRAMS. 0 MI BANK DIRECTOR (M HOGAN) 136577 MR. HOGAN IS EXECUTIVE VICE PRESIDENT & CHIEF CREDIT OFFICER OF M&I MARSHALL & ILSLEY BANK, INC. THE ORGANIZATION PAID $136,577 TO MARSHALL & ILSLEY TRUST COMPANY N.A., AN AFFILIATE OF M&I MARSHALL & ILSLEY BANK, INC., FOR INVESTMENT SERVICES. 0 JOHNSON CONTROLS INC DIRECTOR (CD MYERS) 301911 MR. MYERS IS PRESIDENT-BUILDING EFFICIENCY DIVISION OF JOHNSON CONTROLS, INC. THE ORGANIZATION PAID $301,911 TO JOHNSON CONTROLS, INC. FOR HEATING, VENTILATION, AND AIR CONDITIONING INSTALLATION AND REPAIR. 0 HUMANA DIRECTOR (L RAMBO) 661498 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 $661,498. 0 HUMANA DIRECTOR (L RAMBO) 30495545 MR. RAMBO IS THE REGIONAL CHIEF EXECUTIVE OFFICER OF HUMANA, INC. THE ORGANIZATION RECEIVED APPROXIMATELY $30,495,545 FROM HUMANA FOR HEALTH CARE SERVICES PROVIDED TO HUMANA ENROLLEES. 0 X MEDICAL EQUIPMENT 1 212940 REPLACEMENT COST 0 1 0 METHOD FOR DETERMINING NUMBER OF CONTRIBUTORS: PART I, COLUMN (B): CHILDREN'S HOSPITAL OF WISCONSIN, INC. RECEIVED AN ULTRASOUND MACHINE VALUED AT $212,940, BASED ON WHAT IT WOULD HAVE COST THE HOSPITAL TO BUY A SIMILAR MACHINE. FORM 990, PART VI, SECTION A, LINE 2 BUSINESS RELATIONSHIPS EXIST BETWEEN THE FOLLOWING BOARD MEMBERS: ABRAHAM AND ROTHMAN; BRENNER AND DRURY; BRENNER AND O. SULLIVAN; DRURY AND SOMMERHAUSER; DRURY AND SCHLIFSKE; DRURY AND O. SULLIVAN; SCHLIFSKE AND SOMMERHAUSER; SOMMERHAUSER AND HERMA; AND O. SULLIVAN AND KLIEGMAN. FORM 990, PART VI, SECTION A, LINE 4 THE ARTICLES OF INCORPORATION AND BYLAWS OF THE HOSPITAL WERE AMENDED IN 2010 AS PART OF A SYSTEM-WIDE RESTRUCTURING. THE COMPOSITION OF THE BOARD OF DIRECTORS WAS CHANGED TO CREATE A SHARED BOARD OF DIRECTORS WITH CHILDREN'S HOSPITAL AND HEALTH SYSTEM, INC. ("CHHS"), THE HOSPITAL'S SOLE CORPORATE MEMBER. FORM 990, PART VI, SECTION A, LINE 6 THE ORGANIZATION HAS A SOLE CORPORATE MEMBER WHICH IS CHHS. FORM 990, PART VI, SECTION A, LINE 7A CHHS, THE SOLE CORPORATE MEMBER OF THE ORGANIZATION, ELECTS THE ORGANIZATION'S GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE CORPORATE MEMBER, CHHS, HAS CERTAIN RESERVE POWERS OVER THE CORPORATION, INCLUDING AMENDMENT OF THE ARTICLES OF INCORPORATION AND BYLAWS; APPROVAL OF MERGER, CONSOLIDATION OR THE CREATION OF ANY SUBSIDIARIES BY THE CORPORATION; APPROVAL OF THE ANNUAL BUDGET AND ANY DEBT; AND SELECTION OF THE PRESIDENT. 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 CHW. 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 OF CHHS. 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 PRESIDENT, EXECUTIVE VP, TREASURER, SECRETARY, VP OF REGIONAL SERVICES (DUNCAN), VP CHIEF MEDICAL OFFICER, AND VP OF PATIENT CARE SERVICES WAS REVIEWED AND APPROVED BY THE 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 KEY EMPLOYEES 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 GAINS ON INVESTMENTS: 3,609,238. CHANGE IN FAIR VALUE OF INTEREST RATE SWAP AGREEMENT -6,718,250. INCREASE IN BENEF. INTEREST IN NET ASSETS OF CHILDREN'S HOSPITAL FOUNDATION 31,146,294. PENSION-RELATED CHANGES OTHER THAN NET PERIODIC PENSION COST -14,173,716. TOTAL TO FORM 990, PART XI, LINE 5: 13,863,566. FORM 990, SCHEDULE R, PART V, LINE 1E: PURSUANT TO AN AMENDED AND RESTATED MASTER TRUST INDENTURE DATED MAY 1, 2004, CHILDREN'S HOSPITAL OF WISCONSIN, INC. AND CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION, INC. ARE MEMBERS OF AN OBLIGATED GROUP WHICH JOINTLY AND SEVERALLY GUARANTEE CERTAIN DEBT ISSUED BY A MEMBER OF THE OBLIGATED GROUP THROUGH THE WISCONSIN HEALTH AND EDUCATIONAL FACILITIES AUTHORITY. PAYMENT OF SCHEDULED PRINCIPAL AND INTEREST IS SECURED BY A PLEDGE OF THE HOSPITAL'S AND FOUNDATION'S GROSS UNRESTRICTED RECEIPTS. CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391500074 OPERATIONAL SUPPORT SERVICES WI 501(C)(3) LINE 3 N/A 0 CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391500075 FUND DEVELOPMENT WI 501(C)(3) LINE 7 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 1 CHILDREN'S MEDICAL GROUP INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391789197 PEDIATRIC PHYSICIAN SERVICES WI 501(C)(3) LINE 3 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 1 CHILDREN'S PHYSICIAN GROUP PC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 364303682 PEDIATRIC PHYSICIAN SERVICES IL 501(C)(3) LINE 9 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 1 CHILDREN'S SERVICE SOCIETY OF WISCONSIN 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 390806380 CHILD WELFARE SERVICES WI 501(C)(3) LINE 7 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 1 CHILDREN'S COMMUNITY HEALTH PLAN INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 271494977 WISCONSIN MEDICAID HMO WI 501(C)(3) LINE 9 CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC 1 MEDICAL COLLEGE OF WISCONSIN AFFILIATED HOSPITALS INC 8701 WATERTOWN PLANK ROAD MILWAUKEE WI 53226 391341366 GRADUATE MEDICAL EDUCATION SUPPORT WI 501(C)(3) LINE 11 TYPE 1 N/A 0 VIRTUAL PICU SYSTEMS LLC 401 WYTHE STREET SUITE 101 ALEXANDRIA VA 22314 201414664 QUALITY/OUTCOMES ANALYSIS DE CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC RELATED 0 0 MED-HEALTH FINANCIAL SERVICES INC 9000 W WISCONSIN AVE PO BOX 1997 MILWAUKEE WI 53201 391547907 COLLECTION SERVICES WI CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC C 1 1 1 0 1 0 0 0 1 1 1 1 0 0 1 1 0 1 CHILDREN'S MEDICAL GROUP INC - RENT (LINE 1A (IV) ABOVE) A 331667 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN - RENT (LINE 1A (IV) ABOVE) A 6358 CASH PAID/RECEIVED CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC - RENT (LINE 1A (IV) ABOVE) A 30359 CASH PAID/RECEIVED CHILDREN'S PHYSICIAN GROUP PC B 3700000 CASH PAID/RECEIVED CHILDREN'S MEDICAL GROUP INC B 883130 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN B 2524754 CASH PAID/RECEIVED CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION INC C 5127017 CASH PAID/RECEIVED CHILDREN'S HOSPITAL AND HEALTH SYSTEM FOUNDATION INC E 253200977 NET BOOK VALUE CHILDREN'S MEDICAL GROUP INC K 78234 CASH PAID/RECEIVED CHILDREN'S COMMUNITY HEALTH PLAN INC - PATIENT REIMBURSEMENT K 10042213 CASH PAID/RECEIVED CHILDREN'S SERVICE SOCIETY OF WISCONSIN K 358505 CASH PAID/RECEIVED MED-HEALTH FINANCIAL SERVICES INC L 978096 CASH PAID/RECEIVED CHILDREN'S COMMUNITY HEALTH PLAN INC - ASSESSMENT PASS THROUGH PAYMENTS R 4464323 CASH PAID/RECEIVED