efile Public Visual Render
ObjectId: 201701329349304840 - Submission: 2017-05-12
TIN: 31-0833936
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 Hospital Medical Center
Employer identification number
31-0833936
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
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
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
No
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
Margaret Hostetter
Chair, Pediatrics
(i)
(ii)
565,511
-------------
0
459,817
-------------
0
93,875
-------------
0
71,202
-------------
0
11,818
-------------
0
1,202,223
-------------
0
0
-------------
0
2
Daniel von Allmen MD
Surgeon-in-Chief
(i)
(ii)
809,921
-------------
0
60,656
-------------
0
45,527
-------------
0
103,528
-------------
0
24,228
-------------
0
1,043,860
-------------
0
0
-------------
0
3
Michael Fisher
President & CEO
(i)
(ii)
948,909
-------------
0
100,000
-------------
0
486,077
-------------
0
193,071
-------------
0
29,226
-------------
0
1,757,283
-------------
0
442,787
-------------
0
4
Mark Mumford
SVP & CFO, Treasurer
(i)
(ii)
517,191
-------------
0
155,578
-------------
0
69,411
-------------
0
109,702
-------------
0
27,909
-------------
0
879,791
-------------
0
26,721
-------------
0
5
Beth Stautberg
Secretary, Sr VP & Counsel
(i)
(ii)
462,278
-------------
0
146,849
-------------
0
120,471
-------------
0
96,995
-------------
0
10,610
-------------
0
837,203
-------------
0
83,607
-------------
0
6
Brian Coley
Radiologist-in-Chief
(i)
(ii)
587,423
-------------
0
155,627
-------------
0
146,825
-------------
0
122,294
-------------
0
21,731
-------------
0
1,033,900
-------------
0
104,251
-------------
0
7
Jennifer Dauer
SVP Strategy & Growth
(i)
(ii)
422,203
-------------
0
129,700
-------------
0
42,690
-------------
0
92,191
-------------
0
29,758
-------------
0
716,542
-------------
0
0
-------------
0
8
Steve Davis
COO (Start 9/15)
(i)
(ii)
152,592
-------------
0
0
-------------
0
54,500
-------------
0
51,665
-------------
0
8,134
-------------
0
266,891
-------------
0
0
-------------
0
9
Cheryl Hoying RN-PhD
SVP Patient Services
(i)
(ii)
403,574
-------------
0
120,588
-------------
0
108,071
-------------
0
86,878
-------------
0
15,771
-------------
0
734,882
-------------
0
64,781
-------------
0
10
Dean Kurth through 616
Anesthesiologist-in-Chief
(i)
(ii)
667,181
-------------
0
170,626
-------------
0
164,449
-------------
0
137,788
-------------
0
18,006
-------------
0
1,158,050
-------------
0
117,631
-------------
0
11
David Morales
Prof/Div Dir, Cardiology
(i)
(ii)
1,424,831
-------------
0
150,000
-------------
0
39,978
-------------
0
26,500
-------------
0
25,601
-------------
0
1,666,910
-------------
0
0
-------------
0
12
Francesco Mangano
Prof/Div Dir, Neurosurgery
(i)
(ii)
846,578
-------------
0
184,943
-------------
0
34,353
-------------
0
26,500
-------------
0
36,079
-------------
0
1,128,453
-------------
0
0
-------------
0
13
Andrew Redington
Institute Director - Cardiology
(i)
(ii)
740,049
-------------
0
514,170
-------------
0
1,081,945
-------------
0
112,512
-------------
0
21,875
-------------
0
2,470,551
-------------
0
0
-------------
0
14
Frederick Ryckman
Sr. VP Medical Operations
(i)
(ii)
570,176
-------------
0
196,241
-------------
0
472,146
-------------
0
87,916
-------------
0
2,203
-------------
0
1,328,682
-------------
0
410,166
-------------
0
15
James Tweddell
Institute Director - Cardiothoracic
(i)
(ii)
853,458
-------------
0
400,000
-------------
0
18,818
-------------
0
153,251
-------------
0
11,078
-------------
0
1,436,605
-------------
0
0
-------------
0
16
Richard Azizkhan
Former Surgeon-in-Chief
(i)
(ii)
796,590
-------------
0
278,611
-------------
0
2,009,393
-------------
0
114,320
-------------
0
2,185
-------------
0
3,201,099
-------------
0
1,973,140
-------------
0
17
Scott Hamlin
Former COO (through 4/15)
(i)
(ii)
190,498
-------------
0
212,393
-------------
0
1,383,446
-------------
0
54,814
-------------
0
18,396
-------------
0
1,859,547
-------------
0
858,976
-------------
0
18
Vicki Davies
Treasurer (through 6/15)
(i)
(ii)
108,096
-------------
0
46,270
-------------
0
2,310
-------------
0
0
-------------
0
9,393
-------------
0
166,069
-------------
0
0
-------------
0
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 4b
Certain officers and key employees 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 key employees 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 Cincinnati Children'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. Richard Azizkhan - $87,820 2. Michael Fisher - $166,571 3. Scott Hamlin - $28,314 4. Beth Stautberg - $70,495 5. Dean Kurth - $111,288 6. Mark Mumford - $83,202 7. Stephen Davis - $30,646 8. Margaret Hostetter - $44,702 9. Fred Ryckman - $61,416 10. Andrew Redington - $86,012 11. James Tweddell - $126,751 12. Daniel von Allmen - $77,028 13. Cheryl Hoying - $60,378 14. Jennifer Dauer - $65,691 15. Brian Coley - $95,794 The following is a listing of officers and key employees that received a payment under Cincinnati Children's IRC Sec. 457(f) plan during the year (these amounts are included in the totals for Schedule J, Part II, Column B(iii) and column (F): 1. Richard Azizkhan - $1,973,474 2. Scott Hamlin - $858,976 3. Beth Stautberg - $83,607 4. Dean Kurth - $117,631 5. Fred Ryckman - $410,166 6. Michael Fisher - $442,787 7. Mark Mumford - $26,721 8. Margaret Hostetter - $44,702 9. Cheryl Hoying - $61,416 10. Brian Coley - $104,251
Schedule J, Part II
Scott Hamlin left Cincinnati Children's in April 2015. In connection with his departure, he received a continuation of salary, a payout of previously reported deferred compensation, and will receive two future payments (July 2016 and July 2017) contingent on meeting certain requirements
Schedule J, Explanation of Benefits
The employee benefit plan contribution amounts listed on Schedule J, Part II may include one or more of the following benefits: 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 990, 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 and key employees listed on Form 990, Part VII and Schedule J, Part II are also eligible for any other available employee benefits. Cincinnati Children's officers, trustees, and key employees listed on Form 990, Part VII and Schedule J may incur various travel and entertainment expenses in the conduct of their official duties as representatives of the organization. Cincinnati Children's has a written travel and entertainment expense reimbursement policy that complies with published IRS guidance. All officers, trustees, and key employees are required to substantiate each travel and entertainment expense to the extent as stated in the travel and entertainment expense reimbursement policy. Beyond the officers and key employees listed on Schedule J, Part II, Cincinnati Children's is governed by a board of trustees who are neither compensated for their services provided nor do they receive any fringe benefits (other than free parking) from Cincinnati Children's. Please see Form 990, Part VII for a listing of these trustees. Compensation Committee Philosophy: The Compensation & Management Development Committee (the "Committee") is comprised of trustee members. The Committee is charged with responsibility for review, approval, and oversight of all of the items of compensation that impact Cincinnati Children's senior management and those individuals described in the Committee's charter. The Committee establishes Cincinnati Children's compensation philosophy for these employees by utilizing the following fundamental concepts in determining compensation strategy and objectives: 1. Cincinnati Children's is an equal opportunity employer. Compensation decisions at Cincinnati children's are based upon an employee's performance and his or her achievement of Cincinnati Children's mission; 2. Cincinnati Children's total compensation must remain competitive within, and responsive to, the various regional, national, and global markets which enables it to attract and retain senior management, highly-compensated non-faculty employees and faculty members with the talent and expertise necessary for it to carry out its mission and to be a global leader in pediatric health care, research and education; specific detailed attention is given to relevant comparative compensation data from entities of comparable size, complexity, and global reputation, including other national health care organizations with annual net revenues similar to that of Cincinnati Children's; 3. Cincinnati Children's utilizes external, independent experts to assist in ensuring a complete understanding of all relevant markets; and 4. Cincinnati Children's compensation must not result in private inurement. In addition to their base salary, key members of senior and middle management are eligible for annual incentive compensation. Annual incentive compensation is calculated as a percentage of base salary and is based on achieving certain operational, quality, patient safety, financial and other performance targets that are established on both an organizational and individual level. These performance targets are reviewed and approved by the Compensation Committee on an annual basis.
Schedule J (Form 990) 2015
Additional Data
Software ID:
Software Version: