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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.
Graphic Arrow Attach to Form 990.
Graphic Arrow Go to www.irs.gov/Form990 for the latest information.
OMB No. 1545-0047
2021
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) ACCESS COMMUNITY HEALTH CENTERS
2901 W BELTLINE HWY SUITE 120
MADISON,WI54303 		39-1391134 501 ( C ) (3) 7,568 0     DENTAL SEALANT
(2) ASCENSION WI FOUNDATION INC
2320 N LAKE DRIVE
MILWAUKEE,WI54952 		39-1494981 501 ( C ) (3) 34,393 0     DENTAL SEALANT
(3) CLARK COUNTY HEALTH DEPARTMENT
517 COURT STREET ROOM 105
NIELLSVILLE,WI53094 		39-6005679 CLARK COUNTY 8,397 0     DENTAL SEALANT
(4) DUKE UNIVERSITY
PO BOX 602564
CHARLOTTE,NC53211 		56-0532129 COLLEGE 185,612 0     NIH RESEARCH GRANT
(5) FEEDING AMERICA EASTERN WISCONSIN
1700 W FOND DU LAC AVENUE
MILWAUKEE,WI53223 		39-1384593 501 ( C ) (3) 17,000 0     MEDICAL HOME STATE OF WISCONSIN DPH
(6) HEALTHNET OF ROCK COUNTY
23 W MILWAUKEE STREET 201
JANESVILLE,WI28260 		39-1778804 501 ( C ) (3) 29,909 0     DENTAL SEALANT
(7) JUST KIDS DENTAL
1313 FAIRGROUNDS ROAD
TWO HARBORS,MN54843 		27-2311353 501 ( C ) (3) 13,736 0     DENTAL SEALANT
(8) LAKES COMMUNITY HEALTH CENTER-NORTH LAKES COMMUNITY CLINIC
7665 US HWY 2
IRON RIVER,WI53201 		35-2297925 501 ( C ) (3) 62,744 0     DENTAL SEALANT
(9) LEVEL UP INFECTION PREVENTION
146 RIVER BREEZE DRIVE
CHARLESTON,SC53226 		85-1412091 501 ( C ) (3) 17,750 0     DENTAL SEALANT
(10) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53226 		39-0806261 501 ( C ) (3) 52,567 0     COIIN GRANT
(11) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53226 		39-0806261 501 ( C ) (3) 11,023 0     CONGENITAL DISORDERS STATE OF WISCONSIN DPH
(12) MEDICAL COLLEGE OF WISCONSIN
1155 N MAYFAIR RD
MILWAUKEE,WI53142 		39-0806261 501 ( C ) (3) 6,820 0     SPINA BIFIDA UMPIRE FEDERAL GRANT
(13) PREFERRED DENTISTRY ASSOCIATION OF WISCONSIN LLC
1029 HOWARD ST
EVANSTON,IL54481 		27-2634563 501 ( C ) (3) 12,510 0     DENTAL SEALANT
(14) PROFESSIONAL DENTAL HYGIENE EXPRESS
5388 STATE HWY 64
BLOOMER,WI60202 		27-4969600 501 ( C ) (3) 35,634 0     DENTAL SEALANT
(15) SALVATION ARMY
2400 N TIBBS AVENUE
INDIANPOLIS,WI54555 		36-2167910 501 ( C ) (3) 15,000 0     MEDICAL HOME STATE OF WISCONSIN DPH
(16) SAUK COUNTY
505 BROADWAY
BARABOO,WI53913 		39-6005740 SAUK COUNTY 11,590 0     DENTAL SEALANT
(17) SEALS ON WHEELS
1710 GOLDEN OAK LN
MADISON,WI53711 		38-8086637 501 ( C ) (3) 35,611 0     DENTAL SEALANT
(18) UNIVERSITY OF CHICAGO
5841 S MARYLAND AVENUE
CHICAGO,IL54166 		36-2177139 COLLEGE 32,813 0     NIH RESEARCH GRANT
(19) UNIVERSITY OF WISCONSIN-MADISON
21 N PARK STREET SUITE 6401
MADISON,WI54773 		39-6006492 STATE COLLEGE 57,120 0     COIIN GRANT
(20) WOOD COUNTY
400 MARKET STREET
WISCONSIN RAPIDS,WI53715 		39-6005763 WOOD COUNTY 39,709 0     DENTAL SEALANT
(21) CHILDREN'S HOSPITAL AND HEALTH SYSTEM INC
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-1500074 501 ( C ) (3) 2,883,347 0     GRANTS TO AFFILIATE
(22) CHILDREN'S SERVICE SOCIETY OF WISCONSIN
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-0806380 501 ( C ) (3) 8,913,054 0     GRANTS TO AFFILIATE
(23) CHILDREN'S MEDICAL GROUP INC
PO BOX 1997 MS 900
MILWAUKEE,WI53201 		39-1789197 501 ( C ) (3) 13,396,351 0     GRANTS TO AFFILIATE
2
Enter total number of section 501(c)(3) and government organizations listed in the line 1 table ................. Graphic Arrow
21
3
Enter total number of other organizations listed in the line 1 table ........................ . Graphic Arrow
0
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50055P
Schedule I (Form 990) 2021

Schedule I (Form 990) 2021
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) 2021



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