Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
SchJMediumBullet Attach to Form 990.
MediumBullet Go to www.irs.gov/Form990 for instructions and the latest information.
OMB No. 1545-0047
2017
Open to Public Inspection
Name of the organization
MCCULLOUGH-HYDE MEMORIAL HOSPITAL
INCORPORATED
Employer identification number

31-0650283
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.
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.
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 nonfixed
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) 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
1ROBERT COLLINS MD
DIRECTOR (END 12/17)
(i)

(ii)
0
-------------
442,689
0
-------------
132,072
0
-------------
25,782
0
-------------
148,839
0
-------------
16,908
0
-------------
766,290
0
-------------
0
2MARK CLEMENT
SECRETARY
(i)

(ii)
0
-------------
1,064,319
0
-------------
361,237
0
-------------
17,874
0
-------------
297,460
0
-------------
18,227
0
-------------
1,759,117
0
-------------
0
3GAIL DONOVAN
VICE CHAIR
(i)

(ii)
0
-------------
692,100
0
-------------
215,255
0
-------------
17,585
0
-------------
192,834
0
-------------
9,139
0
-------------
1,126,913
0
-------------
0
4JASON NIEHAUS
DIRECTOR
(i)

(ii)
0
-------------
397,240
0
-------------
94,600
0
-------------
11,354
0
-------------
74,904
0
-------------
23,885
0
-------------
601,983
0
-------------
0
5MICHAEL CROFTON
ASSISTANT TREASURER
(i)

(ii)
0
-------------
302,565
0
-------------
64,965
0
-------------
25,719
0
-------------
88,719
0
-------------
28,454
0
-------------
510,422
0
-------------
0
6BRETT KIRKPATRICK
EXECUTIVE DIRECTOR-MHMH
(i)

(ii)
0
-------------
195,585
0
-------------
42,081
0
-------------
594
0
-------------
19,128
0
-------------
25,790
0
-------------
283,178
0
-------------
0
7GREGORY CALKINS MD
PHYSICIAN
(i)

(ii)
191,208
-------------
0
0
-------------
0
0
-------------
0
188
-------------
0
28,530
-------------
0
219,926
-------------
0
0
-------------
0
8SHARON HANCOCK
SITE DIRECTOR - HR
(i)

(ii)
135,493
-------------
0
7,633
-------------
0
2,433
-------------
0
188
-------------
0
28,317
-------------
0
174,064
-------------
0
0
-------------
0
9JOHN PROUT
FORMER OFFICER
(i)

(ii)
0
-------------
0
0
-------------
0
0
-------------
252,304
0
-------------
0
0
-------------
0
0
-------------
252,304
0
-------------
12,304
10DWIGHT ELLINGWOOD
FORMER OFFICER
(i)

(ii)
0
-------------
0
0
-------------
0
0
-------------
188,878
0
-------------
0
0
-------------
9,422
0
-------------
198,300
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
PART I, LINES 4A-B ELIGIBLE EXECUTIVES (GENERALLY VICE PRESIDENTS AND ABOVE) PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990, SCHEDULE J, PART II, COLUMN B IN THE YEAR PAID. THE FOLLOWING INDIVIDUAL LISTED IN SCHEDULE J, PART II, RECEIVED A PAYMENT FROM A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN WHICH WAS TREATED AS TAXABLE COMPENSATION BY TRIHEALTH, INC.: JOHN PROUT - $12,304
PART I, LINES 3 TRIHEALTH, INC., A RELATED ORGANIZATION OF MCCULLOUGH-HYDE MEMORIAL HOSPITAL, USES THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S CEO/EXECUTIVE DIRECTOR: COMPENSATION COMMITTEE, INDEPENDENT COMPENSATION CONSULTANT, COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD/COMPENSATION COMMITTEE.
PART I, LINE 4A THE REPORTABLE INDIVIDUALS OF MCCULLOUGH-HYDE MEMORIAL HOSPITAL, INCORPORATED ARE PAID BY TRIHEALTH, INC., A RELATED ORGANIZATION, RECOGNIZED BY THE INTERNAL REVENUE SERVICE AS EXEMPT FROM FEDERAL INCOME TAX UNDER INTERNAL REVENUE CODE SECTION 501(A) AS AN ORGANIZATION DESCRIBED IN INTERNAL REVENUE CODE SECTION 501(C)(3). TRIHEALTH, INC. HAS A STANDARD EMPLOYEE SEVERANCE PACKAGE. GENERAL SEVERANCE PAY IS BASED ON LENGTH OF SERVICE. IN ADDITION, NOTICE PAY, IF APPLICABLE UNDER TRIHEALTH, INC. POLICY, MAY BE ADDED TO THE SEVERANCE PACKAGE AND THE AMOUNT OF NOTICE PAY WILL BE DETERMINED BY HUMAN RESOURCES IN ACCORDANCE WITH TRIHEALTH, INC. POLICY. PAYMENTS OF SEVERANCE ARE CONDITIONED UPON SIGNING A SEPARATION AND RELEASE AGREEMENT. DURING THE 2017 CALENDAR YEAR, THE FOLLOWING REPORTABLE INDIVIDUAL(S) RECEIVED SEVERANCE PAYMENTS FROM TRIHEALTH, INC.: DWIGHT ELLINGWOOD - $183,894
Schedule J (Form 990) 2017
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