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ObjectId: 201733199349301763 - Submission: 2017-11-15
TIN: 35-1814660
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
16
Open to Public Inspection
Name of the organization
INDIANA UNIVERSITY HEALTH WEST HOSPITAL
INC
Employer identification number
35-1814660
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 nonfixed
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) 2016
Page 2
Schedule J (Form 990) 2016
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
DANIEL F EVANS JR
DIRECTOR
(i)
(ii)
0
-------------
1,158,577
0
-------------
302,286
0
-------------
62,553
0
-------------
260,986
0
-------------
13,571
0
-------------
1,797,973
0
-------------
0
2
JOHN F FITZGERALD MD
DIRECTOR
(i)
(ii)
0
-------------
321,115
0
-------------
80,993
0
-------------
9,887
0
-------------
125,887
0
-------------
336
0
-------------
538,218
0
-------------
0
3
JAMES T PARKER
DIRECTOR
(i)
(ii)
0
-------------
427,772
0
-------------
204,100
0
-------------
7,883
0
-------------
89,855
0
-------------
31,049
0
-------------
760,659
0
-------------
0
4
KENNETH D PUCKETT
PRESIDENT & CEO
(i)
(ii)
0
-------------
288,435
0
-------------
26,252
0
-------------
2,554
0
-------------
67,046
0
-------------
27,938
0
-------------
412,225
0
-------------
0
5
JEROME P KELLY
SECRETARY (PARTIAL YEAR)
(i)
(ii)
0
-------------
124,553
0
-------------
35,064
0
-------------
36,795
0
-------------
6,966
0
-------------
13,868
0
-------------
217,246
0
-------------
0
6
DEREK E EMPIE
SECRETARY
(i)
(ii)
0
-------------
172,175
0
-------------
1,312
0
-------------
300
0
-------------
9,135
0
-------------
28,169
0
-------------
211,091
0
-------------
0
7
ARTHUR VASQUEZ
TREASURER/COO/CFO
(i)
(ii)
0
-------------
129,835
0
-------------
18,000
0
-------------
20,056
0
-------------
4,985
0
-------------
20,490
0
-------------
193,366
0
-------------
0
8
ANDREW D NIGH MD
CMO
(i)
(ii)
0
-------------
743,642
0
-------------
7,500
0
-------------
10,864
0
-------------
17,225
0
-------------
7,383
0
-------------
786,614
0
-------------
0
9
LISA A SPARKS RN
VP & CNO
(i)
(ii)
158,746
-------------
0
12,403
-------------
0
510
-------------
0
8,977
-------------
0
26,673
-------------
0
207,309
-------------
0
0
-------------
0
10
JAMES R BILLMAN
PHARMACIST
(i)
(ii)
158,932
-------------
0
1,170
-------------
0
516
-------------
0
1,568
-------------
0
0
-------------
0
162,186
-------------
0
0
-------------
0
11
LAURA A ROGGY
PHARMACIST
(i)
(ii)
146,398
-------------
0
1,171
-------------
0
4,808
-------------
0
7,918
-------------
0
17,020
-------------
0
177,315
-------------
0
0
-------------
0
12
LISA M SHOSTRAND RN
REGISTERED NURSE SR. PARTNER
(i)
(ii)
143,290
-------------
0
2,072
-------------
0
3,098
-------------
0
7,645
-------------
0
26,519
-------------
0
182,624
-------------
0
0
-------------
0
13
ERIC D PEAK
PHARMACIST
(i)
(ii)
140,869
-------------
0
1,076
-------------
0
3,041
-------------
0
7,289
-------------
0
6,959
-------------
0
159,234
-------------
0
0
-------------
0
14
PAMELA V CHAPMAN
DIRECTOR, SURGICAL SERVICES
(i)
(ii)
132,396
-------------
0
11,199
-------------
0
282
-------------
0
7,559
-------------
0
27,495
-------------
0
178,931
-------------
0
0
-------------
0
15
STEPHEN H POLLOM MD
FORMER PRESIDENT
(i)
(ii)
0
-------------
218,759
0
-------------
27,802
0
-------------
6,354
0
-------------
14,308
0
-------------
2,550
0
-------------
269,773
0
-------------
0
16
KYLE L ALLEN
FORMER TREASURER
(i)
(ii)
0
-------------
207,072
0
-------------
28,415
0
-------------
21,995
0
-------------
12,807
0
-------------
8,905
0
-------------
279,194
0
-------------
0
17
JUDITH L COLEMAN
FORMER TREASURER
(i)
(ii)
0
-------------
208,421
0
-------------
27,778
0
-------------
1,976
0
-------------
11,993
0
-------------
27,111
0
-------------
277,279
0
-------------
0
18
GREGORY A SPURGIN MD
FOMER CMO
(i)
(ii)
0
-------------
232,368
0
-------------
40,272
0
-------------
6,858
0
-------------
17,225
0
-------------
3,008
0
-------------
299,731
0
-------------
0
19
MATTHEW D BAILEY
FORMER PRESIDENT & CEO
(i)
(ii)
0
-------------
395,853
0
-------------
90,614
0
-------------
26,316
0
-------------
82,274
0
-------------
22,838
0
-------------
617,895
0
-------------
0
Schedule J (Form 990) 2016
Page 3
Schedule J (Form 990) 2016
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, Part I, Line 3 - Comp. of the Org.'s CEO/Executive Director
IU Health West Hospitals President & CEO is employed by IU Health. IU Healths process for determining compensation includes the use of a compensation survey/study conducted by an independent compensation consultant with review and approval by the Committee on Personnel and Compensation and the Board of Directors. Please see Schedule O for additional details.
Schedule J, Part I, Line 4b - Supplemental Nonqualified Retirement Plan
Daniel F. Evans, Jr., John F. Fitzgerald, M.D., James T. Parker, Kenneth D. Puckett, and Matthew D. Bailey participate in an IU Health supplemental executive retirement plan, provisions of which are designed to retain its critical employees. The plan provides for an additional retirement benefit for service through normal retirement or other key dates. If the executive leaves prior to retirement or other key dates, the benefit may be forfeited or reduced. Each of these executives has amounts included in column c, deferred compensation, representing the current year unvested contributions made under the supplemental retirement plan. No amounts were actually paid to these executives during the year.
Schedule J, Part I, Line 7 - Non-Fixed Payments
Amounts disclosed in Column B(ii) include a long-term and short-term incentive for certain executives and short-term incentive for other employees. Although these plans are based on a fixed formula that has been approved by the Board of Directors based upon certain qualitative and quantitative factors and goals, all discretionary incentive plans must be approved by the Board of Directors prior to any incentive payout.
Schedule J (Form 990) 2016
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