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ObjectId: 201813179349300931 - Submission: 2018-11-13
TIN: 75-0800628
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
17
Open to Public Inspection
Name of the organization
Children's Medical Center of Dallas
Employer identification number
75-0800628
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) 2017
Page 2
Schedule J (Form 990) 2017
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
Christopher J Durovich
Former Officer and Director, CMCD & President and CEO, CHST
(i)
(ii)
0
-------------
1,087,098
0
-------------
2,641,501
0
-------------
157,528
0
-------------
12,946
0
-------------
21,791
0
-------------
3,920,864
0
-------------
0
2
Pamela Arora
Former Officer, CMCD & SVP CIO, CHST
(i)
(ii)
0
-------------
415,985
0
-------------
279,084
0
-------------
53,563
0
-------------
72,336
0
-------------
12,092
0
-------------
833,060
0
-------------
0
3
Kimberly Besse
Former Officer, CMCD & SVP Human Resources, CHST
(i)
(ii)
0
-------------
353,876
0
-------------
153,354
0
-------------
53,897
0
-------------
10,761
0
-------------
18,470
0
-------------
590,358
0
-------------
0
4
Keri Kaiser
Former Officer, CMCD & SVP Mrktng and Comm, CHST
(i)
(ii)
0
-------------
288,902
0
-------------
110,636
0
-------------
29,031
0
-------------
10,800
0
-------------
14,848
0
-------------
454,218
0
-------------
0
5
Michele Chulick (term 1617)
Former Officer, CMCD & President CHST Ventures, CHST
(i)
(ii)
0
-------------
20,596
0
-------------
311,646
0
-------------
1,153,129
0
-------------
10,800
0
-------------
0
0
-------------
1,496,171
0
-------------
0
6
Peter Roberts (term 33117)
Former Officer, CMCD & Pres Pop Hlth Insurance Svcs, CHST
(i)
(ii)
0
-------------
152,837
0
-------------
605,165
0
-------------
567,748
0
-------------
16,200
0
-------------
3,380
0
-------------
1,345,330
0
-------------
0
7
Claud Kern Wildenthal MD PhD
Former Officer, CMCD & Consultant, CHST
(i)
(ii)
0
-------------
405,167
0
-------------
0
0
-------------
0
0
-------------
0
0
-------------
0
0
-------------
405,167
0
-------------
0
8
Jerry Lee
Former Officer, CMCD & VP Accounting and Treasury, CHST
(i)
(ii)
0
-------------
278,646
0
-------------
66,547
0
-------------
45,120
0
-------------
14,507
0
-------------
18,282
0
-------------
423,102
0
-------------
0
9
Douglas Duwe
Former Officer, CMCD & VP Academic Relations and Budget Mgmt, CHST
(i)
(ii)
0
-------------
234,934
0
-------------
58,543
0
-------------
37,005
0
-------------
10,762
0
-------------
8,953
0
-------------
350,197
0
-------------
0
10
Mark Ziemianski
Former Officer, CMCD & VP Chief Data Officer, CHST
(i)
(ii)
0
-------------
216,225
0
-------------
60,315
0
-------------
29,078
0
-------------
9,660
0
-------------
16,375
0
-------------
331,653
0
-------------
0
11
Beth Peters (term 81117)
Former Officer, CMCD & VP Corp Compliance and CCO, CHST
(i)
(ii)
0
-------------
147,921
0
-------------
67,079
0
-------------
53,563
0
-------------
12,086
0
-------------
4,155
0
-------------
284,804
0
-------------
0
12
Stephanie Smith
Former Officer, CMCD & Sr Legal Counsel, CHST
(i)
(ii)
0
-------------
124,399
0
-------------
12,883
0
-------------
3,285
0
-------------
6,793
0
-------------
4,213
0
-------------
151,572
0
-------------
0
13
Jaquetta Clemons (term 1117)
Former Officer, CMCD & VP Finance, CHST
(i)
(ii)
0
-------------
0
0
-------------
22,954
0
-------------
348,081
0
-------------
0
0
-------------
0
0
-------------
371,035
0
-------------
0
14
Cynthia Bassel (term 1617)
Former Officer, CMCD & SVP Foundation, CHST
(i)
(ii)
0
-------------
6,927
0
-------------
212,889
0
-------------
638,298
0
-------------
1,784
0
-------------
104
0
-------------
860,002
0
-------------
0
15
David Berry
President, CMCD & President Sys Clin Ops, CHST
(i)
(ii)
0
-------------
584,983
0
-------------
145,155
0
-------------
6,849
0
-------------
10,800
0
-------------
12,132
0
-------------
759,919
0
-------------
0
16
William Morrow MD
EVP CCO, CMCD & Pres Phys Orgs and Acdmc Rel CCO, CHST
(i)
(ii)
0
-------------
556,606
0
-------------
291,820
0
-------------
79,328
0
-------------
10,800
0
-------------
9,067
0
-------------
947,622
0
-------------
0
17
Lawrence Foust
EVP CLO and General Counsel, CMCD & EVP CLO and General Counsel, CHST
(i)
(ii)
0
-------------
511,526
0
-------------
270,308
0
-------------
23,642
0
-------------
10,800
0
-------------
15,012
0
-------------
831,288
0
-------------
0
18
Jeffrey Vawrinek
Secretary, CMCD & Secretary, CHST
(i)
(ii)
0
-------------
294,860
0
-------------
90,417
0
-------------
30,038
0
-------------
9,043
0
-------------
0
0
-------------
424,358
0
-------------
0
19
Richard Goode
EVP CFO and Treasurer, CMCD & EVP CHST Finance CFO and Treas, CHST
(i)
(ii)
0
-------------
638,971
0
-------------
144,875
0
-------------
2,420
0
-------------
10,696
0
-------------
10,644
0
-------------
807,606
0
-------------
0
20
James Herring
EVP CAO, CMCD & EVP CAO, CHST
(i)
(ii)
0
-------------
470,769
0
-------------
0
0
-------------
78,040
0
-------------
16,200
0
-------------
0
0
-------------
565,009
0
-------------
0
21
Mary Stowe RN
SVP CNO, CMCD & SVP and CMC CNO, CHST
(i)
(ii)
0
-------------
342,939
0
-------------
195,123
0
-------------
47,524
0
-------------
19,464
0
-------------
10,805
0
-------------
615,855
0
-------------
0
22
Michael Wiggins
SVP Plano Administrator, CMCD & SVP Plano Administrator
(i)
(ii)
0
-------------
326,093
0
-------------
143,015
0
-------------
1,889
0
-------------
10,800
0
-------------
8,568
0
-------------
490,366
0
-------------
0
23
Matthew Davis
SVP Administrator Children's Medical Center Dallas, CHST
(i)
(ii)
0
-------------
348,399
0
-------------
176,781
0
-------------
23,929
0
-------------
9,836
0
-------------
7,474
0
-------------
566,419
0
-------------
0
24
Kenneth Carr
VP Clinical Support Srvcs
(i)
(ii)
0
-------------
244,641
0
-------------
63,266
0
-------------
33,176
0
-------------
16,200
0
-------------
13,590
0
-------------
370,872
0
-------------
0
25
Joe Cavender
VP and CMC ASSOC CNO
(i)
(ii)
0
-------------
219,869
0
-------------
54,446
0
-------------
27,798
0
-------------
16,599
0
-------------
10,340
0
-------------
329,052
0
-------------
0
26
Dorothy Foglia
VP and CMC ASSOC CNO
(i)
(ii)
0
-------------
220,183
0
-------------
55,787
0
-------------
29,765
0
-------------
15,004
0
-------------
14,642
0
-------------
335,380
0
-------------
0
27
Michael Hefton
VP and CMC ASSOC CNO
(i)
(ii)
0
-------------
213,158
0
-------------
54,465
0
-------------
28,101
0
-------------
13,215
0
-------------
15,305
0
-------------
324,245
0
-------------
0
Schedule J (Form 990) 2017
Page 3
Schedule J (Form 990) 2017
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 Arrangement used to establish the top management official's compensation
CHILDREN'S HEALTH SYSTEM OF TEXAS (EIN 75-2062019) IS THE SOLE MEMBER AND COMMON PAYING AGENT FOR CHILDREN'S MEDICAL CENTER OF DALLAS (CMCD). THEREFORE, Executives, OTHER OFFICERS, AND KEY EMPLOYEES ARE EMPLOYED AND COMPENSATED BY CHILDREN'S HEALTH SYSTEM OF TEXAS (CHST). The CHST process for determining executive compensation is as follows: The Human Resources Committee (Committee) of the CHST Board is responsible for setting the compensation for executives. The Committee is comprised of independent, non-employee directors. A written compensation philosophy has been developed by the Human Resources Committee for timeliness and appropriateness and defines the desired peer groups for compensation surveys. COMPENSATION PROGRAM COMPONENTS: The elements of total compensation provided to CHST executives include: - Cash compensation (i.e., base salary, short-term and long-term incentive compensation, and/or other cash compensation), determined in consideration of competitive market practices, organizational and individual performance, recruitment and retention considerations, and other relevant factors. - Standard benefits, assisting in each executive's medical, dental, disability, life insurance, time off, and retirement needs, reflective of the employment status (i.e., full or part time) of the executive. - Supplemental benefits, including supplemental insurance, retirement benefits, and/or other supplemental benefits determined by the Committee to be appropriate and reasonable in relation to marketplace practices. Compensation and benefits decisions are made in consideration of each executive's position, responsibilities, skills, effort, and performance, in relation to documented practices within the appropriate comparator group(s). PEER GROUP: The Committee has defined its primary peer group for executives as not-for-profit health care organizations similar in size, structure, and complexity. This group will include leading pediatric health systems as well as integrated health systems and academic medical centers. - Data will be compiled in a manner consistent with the IRS Intermediate Sanctions rules of federal tax law, to reflect what is "ordinarily paid to like executives by like enterprises under like circumstances." - In certain circumstances, market data from additional comparator groups (e.g., research institutions, insurance industry, and general industry companies) may also be referenced. - The specific nature of the role at CHST will be considered when adding comparator groups outside of the primary peer group, and the Committee will discuss and agree on the appropriateness of adding comparator groups whenever the specific nature of the CHST role requires additional comparator groups to be used.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
Non-Qualified Retirement Plan: *Retirement Income Restoration Plan - No employees received taxable income from the the Retirement Income Restoration Plan. Employees who participated in the Retirement Income Restoration Plan include Christopher J Durovich and Mary Stowe *Savings Restoration Plan - Michele Chulick received $22,998, Peter Roberts received $76,232, and Cynthia Bassel received $7,964, as taxable income from the Savings Restoration Plan. Additional employees who participated in the Savings Restoration Plan include Christopher J Durovich, Mary Stowe, Pamela Arora, Kimberly Besse, Jerry Lee, and William Morrow.
Schedule J, Part I, Line 7 Non-fixed payments
Non-Fixed Payments - The Human Resources Committee of the Board of Directors of Children's Health System of Texas retains the authority to adjust annual payout percentages solely at their discretion. There were no non-fixed payments in 2017.
Schedule J (Form 990) 2017
Additional Data
Software ID:
17005876
Software Version:
2017v2.2