Department of the Treasury Internal Revenue Service
Public Charity Status and Public Support
Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.
Attach to Form 990 or Form 990-EZ. See separate instructions.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION INC
Employer identification number
62-6002604
Part I
Reason for Public Charity Status
(All organizations must complete this part.) See instructions
The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)
1
2
3
4
5
section 170(b)(1)(A)(iv). (Complete Part II.)
6
7
8
9
receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of
its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses
acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)
10
11
e
By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).
f
If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box
..................................................
g
Since August 17, 2006, has the organization accepted any gift or contribution from any of the following persons?
(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)
Yes
No
and (iii) below, the governing body of the the supported organization?
................
11g(i)
(ii)
a family member of a person described in (i) above?
......................
11g(ii)
(iii)
a 35% controlled entity of a person described in (i) or (ii) above?
................
11g(iii)
h
Provide the following information about the supported organization(s).
(i) Name of supported organization
(ii) EIN
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions))
(iv) Is the organization in col. (i) listed in your governing document?
(v) Did you notify the organization in col. (i) of your support?
(vi) Is the organization in col. (i) organized in the U.S.?
(vii) Amount of support?
Yes
No
Yes
No
Yes
No
Total
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 11285F
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 2
Part II
Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the
organization failed to qualify under Part III. If the organization fails to
qualify under the tests listed below, please complete Part III.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3
The value of services or facilities furnished by a governmental unit to the organization without charge..
4
Total. Add lines 1 through 3..
5
The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included
on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6
Public Support. Subtract line 5 from line 4.
Section B. Total Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
7
Amounts from line 4..
8
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9
Net income from unrelated business activities, whether or not the business is regularly carried on..
10
Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11
Total support (Add lines 7 through 10).
12
Gross receipts from related activities, etc. (See instructions.)
..................
12
13
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here..........................................
Section C. Computation of Public Support Percentage
14
Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f))
.........
14
15
Public Support Percentage for 2009 Schedule A, Part II, line 14
...............
15
16a
33 1/3% support test—2010.
If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization
......................
b
33 1/3% support test—2009.
If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization
.....................
17a
10%-facts-and-circumstances test—2010.
If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization
..................................................
b
10%-facts-and-circumstances test—2009.
If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported organization
..............................................
18
Private Foundation
If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions
...................................................
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 3
Part III
Support Schedule for Organizations Described in IRC 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization
failed to qualify under Part II. If the organization fails to qualify under
the tests listed below, please complete Part II.)
Section A. Public Support
Calendar year(or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
1
Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2
Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3
Gross receipts from activities that are not an unrelated trade or business under section 513..
4
Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5
The value of services or facilities furnished by a governmental unit to the organization without charge..
6
Total. Add lines 1 through 5.
7a
Amounts included on lines 1, 2, and 3 received from disqualified persons...
b
Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c
Add lines 7a and 7b..
8
Public Support (Subtract line 7c from line 6.)
Section B. Total Support
Calendar year (or fiscal year beginning in)
(a) 2006
(b) 2007
(c) 2008
(d) 2009
(e) 2010
(f) Total
9
Amounts from line 6...
10a
Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b
Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c
Add lines 10a and 10b.
11
Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12
Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13
Total support (Add lines 9, 10c, 11 and 12.).
14
First Five Years
If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.............................................
Section C. Computation of Public Support Percentage
15
Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f))
.........
15
16
Public support percentage from 2009 Schedule A, Part III, line 15
...............
16
Section D. Computation of Investment Income Percentage
17
Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f))
......
17
18
Investment income percentage from 2009 Schedule A, Part III, line 17
.............
18
19a
33 1/3% support tests—2010.
If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
..........
b
33 1/3% support tests—2009.
If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization
....
20
Private Foundation
If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions
.....
Schedule A (Form 990 or 990-EZ) 2010
Schedule A (Form 990 or 990-EZ) 2010
Page 4
Part IV
Supplemental Information.
Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).
Facts And Circumstances Test
Explanation
Schedule A (Form 990 or 990-EZ) 2010
Additional Data
Software ID:
Software Version:
-
TIN:
SCHEDULE O (Form 990 or 990-EZ)
Department of the Treasury Internal Revenue Service
Supplemental Information to Form 990 or 990-EZ
Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
Attach to Form 990 or 990-EZ.
OMB No. 1545-0047
2010
Open to Public Inspection
Name of the organization
EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION INC
Employer identification number
62-6002604
Identifier
Return Reference
Explanation
FORM 990, PART VI, SECTION B, LINE 11
THE 2009 FORM 990 AND THE RELATED SCHEDULES ARE PREPARED BY AN UNRELATED, INDEPENDENT ACCOUNTING FIRM AND THEN SUBMITTED TO THE ETCH CFO FOR INTERNAL REVIEW. A DRAFT IS ALSO PROVIDED TO THE ETCH BOARD OF DIRECTORS FINANCE COMMITTEE FOR REVIEW. THE CFO IS AVAILABLE TO ANSWER ANY QUESTIONS RECEIVED FROM THE BOARD AND ADDRESS ANY SIGNIFICANT DISCLOSURES WITHIN THE FORM 990 AND RELATED SCHEDULES PRIOR TO FILING.
FORM 990, PART VI, SECTION B, LINE 12C
EACH MEMBER OF THE BOARD OF DIRECTORS IS ASKED TO REVIEW THE CONFLICT OF INTEREST POLICY AND PROVIDE DISCLOSURE OF ANY ACTIVITIES WHICH COULD CONSTITUTE A CONFLICT OF INTEREST OR POTENTIAL CONFLICT OF INTEREST. THESE CONFLICT OF INTEREST DISCLOSURES ARE REVIEWED BY ETCH'S GENERAL COUNSEL TO ASSURE COMPLIANCE WITH THIS POLICY. ADDITIONALLY, BOARD MEMBERS ARE ASKED TO RECUSE THEMSELVES ON ANY MATTERS OF INTEREST BEFORE THE BOARD IN WHICH A CONFLICT OF INTEREST MAY EXIST. ANY SUCH RECUSAL IS DOCUMENTED WITHIN THE MINUTES OF THE BOARD OR COMMITTEE.
FORM 990, PART VI, SECTION B, LINE 15
THE EXECUTIVE COMMITTEE OF THE ETCH BOARD OF DIRECTORS UTILIZES THE SERVICES OF INDEPENDENT, OUTSIDE COMPENSATION CONSULTANTS TO PROVIDE THE COMMITTEE WITH RELEVANT MARKET DATA FROM STATE AND NATIONAL SALARY SURVEYS FOR COMPARABLE MARKETS. WITH THIS DATA AND THE ADVICE OF OUTSIDE CONSULTANTS, THE ETCH BOARD OF DIRECTORS EXECUTIVE COMMITTEE MAKES RECOMMENDATIONS ON PAY AND BENEFITS FOR THE ETCH PRESIDENT/CEO. THE EXECUTIVE COMMITTEE COMPLETES THIS SAME PROCESS IN MAKING RECOMMENDATIONS FOR ETCH VICE PRESIDENTS.
FORM 990, PART VI, SECTION C, LINE 19
ALL ETCH GOVERNING DOCUMENTS, THE CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST. ADDITIONALLY, FINANCIAL STATEMENTS ARE PROVIDED TO BONDHOLDERS, LOCAL HOSPITALS AND DONORS AND THE CONFLICT OF INTEREST POLICY IS POSTED ON ETCH'S INTRANET.
REIMBURSED COMPENSATION
FORM 990, PART VII
BRYAN PABST AND MARTHA SPARROW ARE EMPLOYED AND RECEIVE A FORM W-2 FROM ETCH. HOWEVER, COMPENSATION FOR THESE INDIVIDUALS IS REIMBURSED BY ANOTHER ORGANIZATION.
CHANGES IN NET ASSETS OR FUND BALANCES:
FORM 990, PART XI, LINE 5:
NET UNREALIZED GAINS ON INVESTMENTS: 4,068,799. EQUITY IN EARNINGS OF SUBSIDIARY -1,600,568. PASSTHRU REVENUE DIFFERENCE -39,887. TEMPORARILY RESTRICTED INVESTMENT INCOME 715,737. TOTAL TO FORM 990, PART XI, LINE 5: 3,144,081.
CONTINUATION OF PROGRAM SERVICE ACCOMPLISHMENTS
FORM 990, PART III, LINE 4A
THE CHILDREN'S HOSPITAL REHABILITATION CENTER WAS ESTABLISHED IN 1947 BY A GROUP OF PARENTS WHOSE CHILDREN HAD CEREBRAL PALSY, AND IT HAS BEEN AN ETCH DEPARTMENT SINCE 1995. THE CENTER PROVIDES REHAB EVALUATION AND TREATMENT SERVICES TO INPATIENTS AT ETCH AND THE CENTER, AS WELL AS HOME HEALTH REHAB THROUGH CHILDREN'S HOSPITAL HOME HEALTH CARE. PATIENTS RANGE FROM THOSE WITH MILD DEVELOPMENTAL DELAYS TO MULTIPLE HANDICAPPING CONDITIONS. ALL SERVICES ARE DESIGNED TO HELP CHILDREN REACH THEIR GREATEST INDEPENDENT FUNCTION AND DEVELOPMENTAL POTENTIAL. IN ADDITION TO OUTPATIENT PHYSICAL AND OCCUPATIONAL THERAPY AND SPEECH PATHOLOGY AT THE CENTER, OUTPATIENT SERVICES ALSO INCLUDE THE CHILDREN'S CORNER MEDICAL DAY TREATMENT PROGRAM, NUTRITION, PSYCHOLOGY, SUMMER DAY CAMP, TRANSPORTATION, PARENT TRAINING AND OUTPATIENT CLINICS AT ETCH. THE CENTER ALSO PROVIDES HIGH-RISK FOLLOW-UP AND SEATING CLINICS. THE CHILDREN'S HOSPITAL REHABILITATION CENTER IS A UNITED WAY AGENCY. ETCH ALSO PROVIDES COMPREHENSIVE CONSULTATION, EVALUATION, DIAGNOSTIC SERVICES AND TREATMENT FOR PEDIATRIC PATIENTS WITH ACUTE, CHRONIC AND/OR COMPLEX CONDITIONS THROUGH THE JAMES S. BUSH OUTPATIENT CARE CENTER. SEVERAL CLINICS FOR SPECIFIC CONDITIONS ARE OFFERED INCLUDING CRANIOFACIAL, CYSTIC FIBROSIS, DERMATOLOGY, DIABETES, GYNECOLOGY, HEMATOLOGY/ONCOLOGY, HIGH RISK, INFECTIOUS DISEASES, METABOLIC DISEASES, MULTISPECIALITY, RHEUMATOLOGY, SPECIAL ATTENTION AND SPASTICITY. A CLINIC VISIT MAY INCLUDE TREATMENT AND CONSULTATION WITH PHYSICIANS, NURSES AND STAFF FROM NUTRITION, SOCIAL WORK, CHILD LIFE, REHABILITATION OR RESPIRATORY CARE. ADDITIONAL SERVICES: THE SOCIAL WORK DEPARTMENT AT ETCH HELPS PATIENTS AND THEIR FAMILIES DEAL WITH EMOTIONAL STRESS CAUSED BY ILLNESS, INJURY OR THE HOSPITALIZATION ITSELF. SOCIAL WORK SERVICES INCLUDE INFORMATION AND REFERRAL; SHORT-TERM SUPPORTIVE COUNSELING FOR PATIENTS AND PARENTS; CRISIS INTERVENTION ASSISTANCE; DISCHARGE PLANNING; FINANCIAL ASSISTANCE; INFORMATION ON SUPPORT AND ADVOCACY GROUPS; AND ASSISTANCE WITH CONCRETE NEEDS, INCLUDING RONALD MCDONALD HOUSE REFERRALS. THE DEPARTMENT ALSO COORDINATES TRANSLATION OF MUCH OF THE HOSPITAL'S PRINTED MATERIAL INTO SPANISH TO GIVE THE HISPANIC POPULATION COMMUNICATION ACCESS WHEN MEDICAL SERVICES ARE PROVIDED. SOCIAL WORK ALSO PROVIDES SEVERAL INTERPRETATION SERVICES FOR ETCH. OPTIMAL PHONE INTERPRETERS IS A TELEPHONE SERVICE THAT PROVIDES INTERPRETERS IN MORE THAN 204 LANGUAGES AND DIALECTS. INTERPRETERS CAN BE ARRANGED FOR FACE-TO-FACE INTERACTIONS BETWEEN SPANISH-SPEAKING PATIENTS AND PARENTS AND THE PHYSICIAN AND/OR OTHER HOSPITAL STAFF MEMBER. SIGN LANGUAGE INTERPRETERS ARE ALSO AVAILABLE FOR HEARING IMPAIRED PATIENTS AND FAMILIES. HOSPITALIZATION, MEDICAL PROCEDURES, ILLNESS AND PAIN ARE OFTEN FEARFUL TIMES FOR PEOPLE OF ALL AGES. THE CHILD LIFE DEPARTMENT AT ETCH IS RESPONSIBLE FOR HELPING CHILDREN COPE WITH THEIR HOSPITALIZATION THROUGH EDUCATION, MEDICAL PLAY AND ACTIVITIES. THE CHILD LIFE STAFF ASSESSES THE CHILD'S FEARS AND NEEDS, EXPLAIN PROCEDURES IN LANGUAGE CHILDREN CAN UNDERSTAND AND USE DISTRACTIONS TO MAKE PROCEDURES, SUCH AS THE PLACEMENT OF AN IV LINE, LESS INTIMIDATING. THE CHILD LIFE STAFF MEMBERS HOLD DEGREES IN EDUCATION, CHILD DEVELOPMENT OR THERAPEUTIC RECREATION. THEY HAVE EXPERTISE IN DEALING WITH A CHILD'S CONCERNS AND REACTIONS TO THE HOSPITAL AND HIS OR HER ILLNESS. IN ADDITION TO ITS WORK WITHIN THE HOSPITAL, THE CHILD LIFE DEPARTMENT ALSO COORDINATES SEVERAL ACTIVITIES FOR CHILDREN IN THE COMMUNITY. PASTORAL CARE - CHAPLAINS ARE AVAILABLE 24 HOURS A DAY TO PROVIDE SPIRITUAL AND EMOTIONAL SUPPORT TO PATIENTS, FAMILIES AND STAFF AT ETCH. CHAPLAINS ALSO PROVIDE CONSULTATION CONCERNING ETHICAL ISSUES RELATED TO PATIENT CARE. FOOD AND NUTRITION SERVICES - ETCH'S CAFETERIA IS OPEN DAILY. VENDING MACHINES ON THE GROUND FLOOR NEAR THE DINING ROOM AND IN THE SCOTT M. NISWONGER EMERGENCY DEPARTMENT WAITING AREA PROVIDE SANDWICHES, SNACKS AND BEVERAGES 24 HOURS A DAY. FOR PATIENTS WITH NO DIETARY RESTRICTIONS, FOOD AND NUTRITION SERVICES OFFERS A SELECTIVE MENU OF IN-ROOM MEALS. ALSO, REGISTERED DIETITIANS PROVIDE CLINICAL NUTRITION SERVICES, AND MEDICAL NUTRITION THERAPY IS AVAILABLE TO INPATIENTS AND OUTPATIENTS WHO ATTEND SPECIALTY CLINICS OR WHO HAVE INDIVIDUAL APPOINTMENTS. THESE SERVICES INCLUDE NUTRITION ASSESSMENT, FEEDING RECOMMENDATIONS, INTAKE EVALUATION AND NUTRITION COUNSELING. ETCH'S HEALTHY KIDS PROGRAM IS A COMMUNITY EDUCATION INITIATIVE OF THE COMMUNITY RELATIONS DEPARTMENT. THE PROGRAM SERVES AS AN EDUCATION RESOURCE FOR PARENTS, GRANDPARENTS AND OTHER CARETAKERS BY OFFERING CLASSES, LITERATURE, A QUARTERLY NEWSLETTER AND OTHER OPPORTUNITIES FOR LEARNING HOW TO IMPROVE THE HEALTH AND WELL-BEING OF CHILDREN. ETCH IS THE LEAD ORGANIZATION FOR AN IMPORTANT AREA COALITION: SAFE KIDS OF THE GREATER KNOX AREA. THE MISSION OF THE LOCAL SAFE KIDS COALITION IS TO REDUCE UNINTENTIONAL INJURIES IN CHILDREN UP TO AGE 14 IN THE EAST TENNESSEE REGION BY PROMOTING AWARENESS AND IMPLEMENTING PREVENTION INITIATIVES. THE LOCAL SAFE KIDS IS PART OF SAFE KIDS WORLDWIDE, A NETWORK OF COALITIONS WHOSE PRIMARY PURPOSE IS TO PREVENT UNINTENTIONAL INJURIES IN CHILDREN BY PROVIDING CHILDREN AND ADULTS CARING FOR THEM WITH INFORMATION ABOUT HOW TO STAY SAFE. HOPP IS HEMATOLOGY/ONCOLOGY PATIENTS AND PARENTS, AN OFFICIAL SUPPORT GROUP OF ETCH THAT PROVIDES SUPPORT FOR FAMILIES DEALING WITH A CHILD WITH CANCER. FOR THE YEAR ENDED JUNE 30, 2011 ETCH HAD 35,942 TOTAL INPATIENT DAYS, 170,757 TOTAL OUTPATIENT VISITS AND 66,839 EMERGENCY DEPARTMENT VISITS.
WHISTLE BLOWER POLICY
FORM 990, PART VI, SECTION B, LINE 13:
THE ORGANIZATION DOES NOT PRESENTLY HAVE A FORMAL WRITTEN WHISTLE BLOWER POLICY; HOWEVER, ETCH DOES HAVE A NON-RETALIATION POLICY. THE ORGANIZATION IS CURRENTLY WORKING TO FORMALIZE A WHISTLE BLOWER POLICY.
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.