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ObjectId: 201711319349305266 - Submission: 2017-05-11
TIN: 54-0506321
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 OF THE KING'S DAUGHTERS
Employer identification number
54-0506321
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
Yes
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
Yes
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
Michelle Brenner MD
Director
(i)
(ii)
0
-------------
205,331
0
-------------
0
0
-------------
229
0
-------------
8,463
0
-------------
15,434
0
-------------
229,457
0
-------------
0
2
James D Dahling
President/Director
(i)
(ii)
0
-------------
912,539
0
-------------
0
0
-------------
82,412
0
-------------
537,442
0
-------------
29,201
0
-------------
1,561,594
0
-------------
61,424
3
Robert Obermeyer MD
Director
(i)
(ii)
0
-------------
631,854
0
-------------
0
0
-------------
314
0
-------------
10,600
0
-------------
22,744
0
-------------
665,512
0
-------------
0
4
Dennis Ryan
CFO/Asst Treas/Assist Secr
(i)
(ii)
0
-------------
478,437
0
-------------
0
0
-------------
34,697
0
-------------
345,680
0
-------------
43,366
0
-------------
902,180
0
-------------
20,537
5
Kathryn Abshire
VP Finance
(i)
(ii)
0
-------------
206,885
0
-------------
0
0
-------------
20,003
0
-------------
32,283
0
-------------
24,167
0
-------------
283,338
0
-------------
8,605
6
Deborah Barnes
VP - IS Operations
(i)
(ii)
0
-------------
312,926
0
-------------
0
0
-------------
22,582
0
-------------
123,951
0
-------------
27,743
0
-------------
487,202
0
-------------
7,710
7
David Bowers
VP - Support Services
(i)
(ii)
201,039
-------------
0
0
-------------
0
2,075,678
-------------
0
10,600
-------------
0
8,850
-------------
0
2,296,167
-------------
0
1,631,552
-------------
0
8
Jo-Ann Burke
VP- Patient Care Services
(i)
(ii)
336,627
-------------
0
0
-------------
0
80,447
-------------
0
10,600
-------------
0
18,057
-------------
0
445,731
-------------
0
0
-------------
0
9
John Harding
Chief Operating Officer
(i)
(ii)
118,439
-------------
322,736
0
-------------
0
3,677
-------------
31,804
10,236
-------------
139,742
8,482
-------------
20,350
140,834
-------------
514,632
0
-------------
0
10
Tamika Harris
VP - Facilities & Support svcs
(i)
(ii)
143,386
-------------
0
12,173
-------------
0
11,806
-------------
0
20,053
-------------
0
7,689
-------------
0
195,107
-------------
0
0
-------------
0
11
Karen Mitchell
VP- Patient Care Services
(i)
(ii)
153,096
-------------
0
11,553
-------------
0
34,167
-------------
0
25,388
-------------
0
8,980
-------------
0
233,184
-------------
0
0
-------------
0
12
Allison Silva
VP - Ancillary Services
(i)
(ii)
198,662
-------------
0
0
-------------
0
30,075
-------------
0
61,114
-------------
0
8,915
-------------
0
298,766
-------------
0
13,008
-------------
0
13
Sandip Godambe MD
VP - Quality & Patient Safety
(i)
(ii)
360,532
-------------
0
0
-------------
0
15,103
-------------
0
76,864
-------------
0
56,252
-------------
0
508,751
-------------
0
3,964
-------------
0
14
Elizabeth Musial
Director Perioperative Service
(i)
(ii)
170,757
-------------
0
17,225
-------------
0
40,614
-------------
0
7,558
-------------
0
2,527
-------------
0
238,681
-------------
0
0
-------------
0
15
James Dice
Director Pharmacy
(i)
(ii)
161,641
-------------
0
14,766
-------------
0
36,600
-------------
0
7,214
-------------
0
10,214
-------------
0
230,435
-------------
0
0
-------------
0
16
Suzanne Starling
Medical Director
(i)
(ii)
204,592
-------------
0
0
-------------
0
1,380
-------------
0
8,438
-------------
0
14,947
-------------
0
229,357
-------------
0
0
-------------
0
17
Rowland Harrison
Director Information Services
(i)
(ii)
130,765
-------------
0
12,337
-------------
0
46,460
-------------
0
0
-------------
0
14,624
-------------
0
204,186
-------------
0
0
-------------
0
18
Joann Rogers
Former VP
(i)
(ii)
0
-------------
0
0
-------------
0
1,888,930
-------------
0
0
-------------
0
0
-------------
0
1,888,930
-------------
0
1,181,687
-------------
0
19
Arno Zarisky
Former VP
(i)
(ii)
240,481
-------------
0
0
-------------
0
1,104,534
-------------
0
10,600
-------------
0
10,198
-------------
0
1,365,813
-------------
0
1,032,719
-------------
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
SCHEDULE J, LINE 1:
IN CONNECTION WITH A RETIREMENT PROGRAM, TAX GROSS-UP PAYMENTS ARE PROVIDED TO CERTAIN DIRECTORS WHOSE EMPLOYER FUNDED CONTRIBUTIONS ARE IMMEDIATELY TAXABLE, IN ORDER TO PROVIDE THEM WITH BENEFITS THAT ARE TAX-EQUIVALENT TO BENEFITS OF PARTICIPANTS WHOSE CONTRIBUTIONS ARE NOT IMMEDIATELY TAXABLE.
SCHEDULE J, LINE 4B:
CHILDREN'S HEALTH SYSTEM SPONSORS A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN ("THE PLAN"). THE PLAN IS DESIGNED TO RETAIN EXECUTIVES IN POSITIONS ESSENTIAL TO THE SUCCESS OF CHILDREN'S HEALTH SYSTEM. DURING THE YEAR, THE FOLLOWING INDIVIDUALS WERE PARTICIPANTS IN A SPONSORED SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN AND RECEIVED THE FOLLOWING PAYMENTS WHICH ARE INCLUDED IN SCHEDULE J PART II COLUMN (C): KATHY ABSHIRE $ 22,461 JAMES DAHLING $ 405,545 KAREN MITCHELL $ 26,231 DENNIS RYAN $ 329,467 ALLISON SILVA $ 37,107 SANDIP GODAMBE $ 67,368 DEBORAH BARNES $ 152,470 TAMIKA HARRIS $ 8,069 JOHN HARDNG $ 124,883 AND IN SCHEDULE J, PART II, COLUMN(B): JOANN ROGERS $ 1,864,851 DAVID BOWERS $ 2,039,534 ARNO ZARITSKY $ 1,032,753
SCHEDULE J, LINE 7
OFFICERS AND VICE PRESIDENTS MAY RECEIVE ADDITIONAL COMPENSATION BASED ON CRITERIA SET UP BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. DEPARTMENT DIRECTORS MAY RECEIVE ADDITIONAL COMPENSATION BASED ON CRITERIA SET BY MANAGEMENT AND APPROVED BY THE BOARD OF DIRECTORS.
Schedule J (Form 990) 2015
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