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Schedule I
(Form 990)
Department of the Treasury
Internal Revenue Service
Grants and Other Assistance to Organizations,
Governments and Individuals in the United States
Complete if the organization answered "Yes," on Form 990, Part IV, line 21 or 22.
lBullet Attach to Form 990.
lBullet Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2020
Open to Public
Inspection
Name of the organization
CHILDREN'S HOSPITAL OF WISCONSIN INC
 
Employer identification number
39-0812532
Part I
General Information on Grants and Assistance
1
Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ........................
2
Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.
Part II
Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered "Yes" on Form 990, Part IV, line 21, for any recipient
that received more than $5,000. Part II can be duplicated if additional space is needed.
(a) Name and address of organization
or government		 (b) EIN (c) IRC section
(if applicable)		 (d) Amount of cash grant (e) Amount of non-cash
assistance		 (f) Method of valuation
(book, FMV, appraisal,
other)		 (g) Description of
noncash assistance		 (h) Purpose of grant
or assistance
(1) BROWN COUNTY ORAL HEALTH PARTNERSHIP
331 N BROADWAY
GREEN BAY,WI54303 		20-8969896   5,256       DENTAL SEALANT
(2) CITY OF MENASHA
140 MAIN STREET
MENASH,WI54952 		39-6005525 CITY OF MENASHA 9,000       DENTAL SEALANT
(3) CITY OF WATERTOWN
106 JONES STREET
WATERTOWN,WI53094 		39-6005640 CITY OF WATERTOWN 6,636       DENTAL SEALANT
(4) COLUMBIA ST MARY'S FOUNDATION INC
HERITAGE CENTER 2320 NORTH LAKE
DRIVE
MILWAUKEE,WI53211 		39-1494981 501 ( C ) (3) 50,000       DENTAL SEALANT
(5) DENTAMED HEALTHCARE LLC
5212 W DONGES LANE
BROWN DEER,WI53223 		81-5225234   49,229       DENTAL SEALANT
(6) DUKE UNIVERSITY
PO BOX 602564
CHARLOTTE,NC28260 		56-0532129 COLLEGE 68,105       NIH RESEARCH GRANT
(7) LAKES COMMUNITY HEALTH DEPARTMENT NORTHLAKES COMMUNITY CLINIC
15910 W COMPANY LAKE ROAD
HAYWARD,WI54843 		35-2297925 501 ( C ) (3) 49,092       DENTAL SEALANT
(8) MARQUETTE UNIVERSITY
PO BOX 1881
MILWAUKEE,WI53201 		39-0806251 501 ( C ) (3) 10,000       DENTAL SEALANT
(9) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53226 		39-0806261 501 ( C ) (3) 62,712       COIIN GRANT
(10) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53226 		39-0806261 501 ( C ) (3) 8,246       CONGENITAL DISORDERS
(11) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53226 		39-0806261 501 ( C ) (3) 6,851       SPINA BIFIDA UMPIRE FEDERAL GRANT
(12) OUTREACH 4 HEALTHY TEETH LLC
9220 66TH STREET
KENOSHA,WI53142 		84-2242837   10,385       DENTAL SEALANT
(13) PORTAGE COUNTY HEALTH AND HUMAN SERVICES
817 WHITING AVENUE
STEVENS POINT,WI54481 		39-6005731 PORTAGE COUNTY 11,103       DENTAL SEALANT
(14) PREFERRED DENTISTRY ASSOCIATION OF WISCONSIN LLC
1029 HOWARD ST
EVANSTON,IL60202 		27-2634563   70,000       DENTAL SEALANT
(15) PRICE COUNTY HEALTH DEPARTMENT
104 S EYDER AVENUE
PHILLIPS,WI54555 		39-6005733 PRICE COUNTY 10,971       DENTAL SEALANT
(16) SAUK COUNTY
505 BROADWAY
BARABOO,WI53913 		39-6005740 SAUK COUNTY 7,678       DENTAL SEALANT
(17) SEALS ON WHEELS
1710 GOLDEN OAK LN
MADISON,WI53711 		38-8086637   22,564       DENTAL SEALANT
(18) SHAWANO COUNTY
311 N MAIN STREET
SHAWANO,WI54166 		39-6005743 SHAWANO COUNTY 18,811       DENTAL SEALANT
(19) TREMPEALEAU COUNTY
36245 MAIN STREET
WHITEHALL,WI54773 		39-6005747 TREMPEALEAU COUNTY 10,900       DENTAL SEALANT
(20) UNIVERSITY OF WISCONSIN-MADISON
21 N PARK STREET SUITE 6401
MADISON,WI53715 		39-6006492 STATE COLLEGE 53,276       COIIN GRANT
(21) UNIVERSITY OF WISCONSIN-MADISON
21 N PARK STREET SUITE 6401
MADISON,WI53715 		39-6006492 STATE COLLEGE 45,000       MEDICAL HOME STATE DPH GRANT
(22) VILAS COUNTY
330 COURT STREET EAGLE
EAGLE RIVER,WI54521 		39-6005751 VILAS COUNTY 15,089       DENTAL SEALANT
(23) WALWORTH COUNTY
PO BOX 1001
ELKHORN,WI53121 		39-6002726 WALWORTH COUNTY 27,069       DENTAL SEALANT
(24) WAUPACA COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES
811 HARDING STREET
WAUPACA,WI54981 		39-6005758 WAUPACA COUNTY 7,560       DENTAL SEALANT
(25) WOOD COUNTY
400 MARKET STREET
WISCONSIN RAPIDS,WI54494 		39-6005763 WOOD COUNTY 12,340       DENTAL SEALANT
(26) CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-1500074 501 ( C ) (3) 21,536,153       GRANTS TO AFFILIATE
(27) CHILDREN'S SERVICE SOCIETY OF WISCONSIN
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-0806380 501 ( C ) (3) 9,909,747       GRANTS TO AFFILIATE
(28) CHILDREN'S MEDICAL GROUP INC
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-1789197 501 ( C ) (3) 25,249,507       GRANTS TO AFFILIATE
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Bullet Image
23
3
Enter total number of other organizations listed in the line 1 table ........................ . Bullet Image
5
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2020

Schedule I (Form 990) 2020
Page 2
Part III
Grants and Other Assistance to Domestic Individuals. Complete if the organization answered "Yes" on Form 990, Part IV, line 22.
Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of
recipients		 (c) Amount of
cash grant		 (d) Amount of
noncash assistance		 (e) Method of valuation (book,
FMV, appraisal, other)		 (f) Description of noncash assistance
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Part IV
Supplemental Information. Provide the information required in Part I, line 2; Part III, column (b); and any other additional information.
Return Reference Explanation
PART I, LINE 2: MONITORING PROCEDURES - THE ORGANIZATION RECEIVES GRANT FUNDING FROM VARIOUS STATE AND FEDERAL AGENCIES. SOME OF THE GRANT AWARDS ARE SUB-AWARDED TO OTHER AGENCIES BASED ON THE REQUIREMENTS OF THE INDIVIDUAL GRANT AGREEMENTS. IN ORDER TO MONITOR THE USE OF THE FUNDS, THE ORGANIZATION ENTERS INTO SIGNED AGREEMENTS WITH THE SUB-GRANTEE AGENCIES TO OUTLINE THE TERMS OF THE ARRANGEMENTS INCLUDING THE PROPER USE OF FUNDS. THESE AGREEMENTS REQUIRE AGENCIES TO PROVIDE CERTIFICATIONS OF EXPENSES SUBMITTED FOR REIMBURSEMENT ALONG WITH DESCRIPTIONS OF THE ACTUAL EXPENSES INCURRED COMPARED TO THE BUDGETED AWARD TOTAL. EACH AWARD IS MONITORED BY A DESIGNATED EMPLOYEE OF THE ORGANIZATION WHO VERIFIES THAT ALL SERVICES ARE PROVIDED ACCORDING TO THE CONTRACT, APPROVES PAYMENTS TO THE AGENCY, AND ENSURES THAT THE AWARD OBJECTIVES ARE MET. IN SOME CASES, THE ORGANIZATION REQUIRES THE AGENCY TO SUBMIT A COPY OF ITS ANNUAL OMB 133 AUDIT ALONG WITH ANY RELEVANT AUDIT FINDINGS. ADDITIONALLY, CHW FUNDS ITS TAX-EXEMPT AFFILIATES. FUNDS ARE AWARDED BASED ON THE STRATEGIC INITIATIVES OF THE HEALTH SYSTEM, THE NEEDS OF THE AFFILIATES, AND ANY PURPOSE RESTRICTIONS SET BY THE DONORS. THE NEEDS OF THE AFFILIATES ARE EVALUATED IN THE ANNUAL BUDGET PROCESS. FINAL BUDGETS REQUIRE APPROVAL FROM MANAGEMENT, THE ENTITY'S BOARD OF DIRECTORS AND THE CHHS BOARD OF DIRECTORS AND SENIOR MANAGEMENT. IN ADDITION, THE OPERATIONS OF ALL AFFILIATES ARE SUBJECT TO SYSTEM CONTROLS, POLICIES AND PROCEDURES, AND ARE REFLECTED IN THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS OF CHHS AND ITS AFFILIATES.
Schedule I (Form 990) 2020



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