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ObjectId: 201603169349303560 - Submission: 2016-11-11
TIN: 41-1754276
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
15
Open to Public Inspection
Name of the organization
Children's Health Care
Employer identification number
41-1754276
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
.........
1b
Yes
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a?
..
2
No
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
................
4a
Yes
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
...........................
5a
No
b
Any related organization?
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
6a
No
b
Any related organization?
.........................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
.............................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2015
Page 2
Schedule J (Form 990) 2015
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2 and/or 1099-MISC compensation
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation in column(B) reported as deferred on prior Form 990
(i)
Base compensation
(ii)
Bonus & incentive compensation
(iii)
Other reportable compensation
1
Robert Segal
Medical Director
(i)
(ii)
209,826
-------------
23,346
-------------
26,289
-------------
39,652
-------------
0
20,808
-------------
0
319,921
-------------
0
18,313
-------------
0
2
Jerry Massmann
Former VP of Finance and CFO
(i)
(ii)
-------------
-------------
305,255
-------------
0
-------------
0
0
-------------
0
305,255
-------------
0
284,877
-------------
0
3
Robert Bonar JR
Chief Executive Officer
(i)
(ii)
817,011
-------------
-------------
185,354
-------------
180,988
-------------
0
17,396
-------------
0
1,200,749
-------------
0
0
-------------
0
4
Alan Goldbloom
Chief Executive Officer
(i)
(ii)
142,714
-------------
428,764
-------------
-------------
16,395
-------------
0
206
-------------
0
588,079
-------------
0
0
-------------
0
5
Alec Mahmood
Chief Financial Officer
(i)
(ii)
383,724
-------------
169,100
-------------
25,440
-------------
14,662
-------------
0
16,095
-------------
0
609,021
-------------
0
19,151
-------------
0
6
Alice Chernich
Sr Dir Clinical SVC Neonatal
(i)
(ii)
160,321
-------------
29,772
-------------
-------------
9,753
-------------
0
13,374
-------------
0
213,220
-------------
0
0
-------------
0
7
Becky Bedore
Sr Dir Clin Svc - Pediatrics
(i)
(ii)
151,226
-------------
29,421
-------------
-------------
24,942
-------------
0
14,155
-------------
0
219,744
-------------
0
0
-------------
0
8
Bjorn Gunnerud
VP, Marketing & Communications
(i)
(ii)
219,407
-------------
66,091
-------------
33,321
-------------
43,559
-------------
0
19,836
-------------
0
382,214
-------------
0
24,494
-------------
0
9
Carol Wilcox
Senior Hospital Admin
(i)
(ii)
202,308
-------------
59,193
-------------
27,674
-------------
40,722
-------------
0
2,302
-------------
0
332,199
-------------
0
22,762
-------------
0
10
David Brumbaugh
Former CHR Officer
(i)
(ii)
-------------
-------------
151,339
-------------
140,778
-------------
0
5,965
-------------
0
298,082
-------------
0
131,259
-------------
0
11
David Overman
President & Chief Operator
(i)
(ii)
491,853
-------------
415,627
-------------
100,598
-------------
105,971
-------------
0
17,396
-------------
0
1,131,445
-------------
0
79,393
-------------
0
12
Gloria Drake
Sr Dir Clin Svcs - Periop
(i)
(ii)
181,403
-------------
35,340
-------------
1,889
-------------
25,380
-------------
0
12,561
-------------
0
256,573
-------------
0
0
-------------
0
13
Jeffrey Young
Chief Information Officer
(i)
(ii)
313,515
-------------
95,310
-------------
38,069
-------------
54,774
-------------
0
19,673
-------------
0
521,341
-------------
0
33,323
-------------
0
14
Jennifer Close
Chief Ambulatory Officer
(i)
(ii)
117,540
-------------
81,796
-------------
1,024
-------------
10,836
-------------
0
4,177
-------------
0
215,373
-------------
0
0
-------------
0
15
Jennifer Olson
VP Business Development
(i)
(ii)
235,099
-------------
40,467
-------------
6,146
-------------
28,514
-------------
0
14,457
-------------
0
324,683
-------------
0
0
-------------
0
16
Maria Christu
Gen Counsel, VP, Advoc & Hlth
(i)
(ii)
354,097
-------------
105,688
-------------
56,126
-------------
62,422
-------------
0
21,355
-------------
0
599,688
-------------
0
40,100
-------------
0
17
Phil Kibort
VP Medical Affairs
(i)
(ii)
480,450
-------------
147,288
-------------
193,893
-------------
24,177
-------------
0
18,212
-------------
0
864,020
-------------
0
81,164
-------------
0
18
Roxanne Fernandes
Chief Nursing Officer
(i)
(ii)
317,518
-------------
96,223
-------------
47,908
-------------
55,447
-------------
0
16,960
-------------
0
534,056
-------------
0
39,736
-------------
0
19
Samantha Hanson
CHRO
(i)
(ii)
295,838
-------------
56,221
-------------
9,585
-------------
51,279
-------------
0
20,724
-------------
0
433,647
-------------
0
0
-------------
0
20
Stephen C Nelson MD
Pediatrician, Board Member
(i)
(ii)
264,164
-------------
42,041
-------------
20,982
-------------
39,838
-------------
0
21,254
-------------
0
388,279
-------------
0
0
-------------
0
21
James Engels
Staff Physician
(i)
(ii)
509,177
-------------
29,682
-------------
79,380
-------------
53,232
-------------
0
22,244
-------------
0
693,715
-------------
0
37,469
-------------
0
22
Joseph Petronio
Surgical Dir, Peds Neurosurg
(i)
(ii)
757,055
-------------
46,126
-------------
88,437
-------------
39,205
-------------
0
23,204
-------------
0
954,027
-------------
0
37,977
-------------
0
23
Meysam Kebriaei
Staff Physician
(i)
(ii)
608,634
-------------
48,001
-------------
11,706
-------------
45,447
-------------
0
22,710
-------------
0
736,498
-------------
0
10,115
-------------
0
24
William Mize
Medical Director
(i)
(ii)
458,296
-------------
72,169
-------------
39,775
-------------
50,704
-------------
0
23,204
-------------
0
644,148
-------------
0
33,004
-------------
0
25
Barbara Malone
Staff Physician
(i)
(ii)
496,099
-------------
32,501
-------------
24,810
-------------
41,523
-------------
0
17,718
-------------
0
612,651
-------------
0
0
-------------
0
26
Kathleen Penson
Director Access/Systems
(i)
(ii)
154,121
-------------
20,277
-------------
959
-------------
2,377
-------------
0
18,130
-------------
0
195,864
-------------
0
0
-------------
0
27
Rebecca Woitalewicz
Interim CFO
(i)
(ii)
166,654
-------------
22,152
-------------
4,440
-------------
12,621
-------------
0
18,176
-------------
0
224,043
-------------
0
0
-------------
0
28
Theresa Pesch
President, Foundation
(i)
(ii)
165,686
-------------
165,686
62,617
-------------
62,617
32,706
-------------
32,706
29,535
-------------
29,535
8,555
-------------
8,555
299,099
-------------
299,099
18,741
-------------
18,740
Schedule J (Form 990) 2015
Page 3
Schedule J (Form 990) 2015
Page
3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference
Explanation
Part I, Line 1a:
Robert Bonar is reimbursed for his membership fees for the Minneapolis Club, which is used solely for business purposes. Part I, Line 4a JERRY MASSMANN BEGAN RECEIVING SEVERANCE PAY ON 8/1/2013 FOR TWO YEARS.HE RECEIVED $280,388 IN 2015. David Brumbaugh received severance pay 4/30/2014 through 6/30/2015. He received $151,339 in 2015.
Part I, Line 4b:
Certain employees of Children's Health Care, parent of Children's Clinic Network, are provided the opportunity to participate in the 457(f) Deferral Plan (the Deferral Plan). The Deferral Plan requires that the employee is a physician or executive and is a .5 FTE or more in order to be eligible to participate in the Deferral Plan. Payments from the Deferral Plan occur at vesting and are based on percentage of salary. The following amounts represent the amount paid under the Deferral Plan in 2015: Maria Christu - $40,100 Phil Kibort - $160,138 Jerry Massmann - $24,868 David Brumbaugh - $131,259 Theresa Pesch - $37,481 David Overman - $87,430 Roxanne Fernandes - $39,736 Jeffrey Young - $33,323 Joseph Petronio - $37,977 William Mize - $33,030 James Engels - $37,469 Robert Segal - $18.313 Meysam Kebriaei - $29,547 Alec Mahmood - $19,151 Carol Wilcox - $23,984 Bjorn Gunnerud - $24,494 Jennifer Olson - $13,394 Barbara Malone - $25,623 Stephen Nelson - $18,062
Schedule J (Form 990) 2015
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