2023 Trinity Health Executive Conflicts of Interest Disclosure Statement

Instruction

The Conflicts of Interest Disclosure Statement is comprised of 14 Yes or No questions about your relationship to Trinity Health and/or your ministry. Your responses should cover the time period of July 1, 2022, through June 30, 2023. If your answer to a question is “Yes,” questions will appear below requiring additional information. Please make all applicable disclosures to a question for the timeframe indicated.

Please Note: This Disclosure Statement does not apply to any relationships that you or a member of your immediate family may have with Trinity Health as a patient of a hospital, clinic or other business owned or operated by Trinity Health in the normal course of business.

Before you begin the survey, please take a moment to review Trinity Health’s Board, Senior Executives and Interested Persons Conflict of Interest Policy.

Questionnaire

1) From July 1, 2022, through June 30, 2023, did you personally perform services for a Trinity Health organization, other than in your capacity as an executive or key employee of a Trinity Health organization?

( ) Yes ( ) No

Provide a description of the services personally performed:

Provide an estimate of the total fees and expenses (e.g., $10,000.00):

$________

Trinity Health organization(s) for which you personally performed services (list all that apply):

2) From July 1, 2022, through June 30, 2023, were you involved in any new or ongoing legal or administrative proceedings, real estate transactions or other non-routine business transactions involving a Trinity Health organization(s), either personally or through a company in which you served as a board member, officer, manager, employee, consultant, or in any other capacity?

( ) Yes ( ) No

Provide a brief description of the legal or administrative proceeding(s), real estate transaction(s), or other business transaction(s):

Provide the name of the company(s) involved:

Indicate your relationship to the company (select one):

( ) Board member

( ) Employee

( ) Consultant

( ) Other - write In:

Trinity Health organization(s) with which business was conducted (list all that apply):

3) From July 1, 2022, through June 30, 2023, did you have any direct or indirect ownership interest(s) in any company(s) with which a Trinity Health organization(s) conducts business, or are you an owner or investor in any joint venture(s) that conducts business with a Trinity Health organization(s)?NOTE: Ownership interests of less than one percent in publicly-traded companies do not require disclosure.

( ) Yes ( ) No

Provide the name of the company(s)/joint venture(s) conducting business with a Trinity Health organization(s):

Provide your direct or indirect ownership percentage (round to nearest whole percent) in company(s)/joint venture(s):

Trinity Health organization(s) with which business was conducted (list all that apply):

4) From July 1, 2022, through June 30, 2023, did you serve as a board member, officer, manager, employee, consultant, or in any other capacity to a company(s) that sells or donates products or services to a Trinity Health organization(s) or purchases products or services from a Trinity Health organization(s)?

NOTE: The routine purchase of medical products and services as a patient of a Trinity Health organization does not require disclosure.

( ) Yes ( ) No

Provide the name of the company(s):

Indicate your relationship to the company (select one):

( ) Board member

( ) Employee

( ) Consultant

( ) Other - write in:

Provide a brief description of the product(s) and/or service(s) provided to or purchased by a Trinity Health organization(s):

Trinity Health organization(s) with which business was conducted (indicate all that apply):

5) From July 1, 2022 through June 30, 2023, did you serve as a board member, officer, manager, employee, consultant, or in any other capacity to a company(s) that provides services in competition with a Trinity Health organization(s), or did you have any direct or indirect ownership or investment interest in any company(s) that provides services in competition with a Trinity Health organization(s)?

Competition means providing a product or service that is also provided by a Trinity Health organization(s) in the same geographic area, or to patients in the same geographic area.

( ) Yes ( ) No

Provide the name of the company(s) that competes with a Trinity Health organization(s):

Brief description of the competitive product(s) and/or service(s) provided:

Indicate your relationship to the company (select one):

( ) Board member

( ) Consultant

( ) Employee

( ) Other (please describe):

6) From July 1, 2022, through June 30, 2023, did you have any employment, appointment, or other relationship with a government entity(s) having regulatory authority over a Trinity Health organization(s)?

( ) Yes ( ) No

Provide the name of the government entity(s):

Provide a brief description of the government entity’s relationship to the Trinity Health organization(s):

Indicate your relationship to the government entity (select one):

( ) Employee

( ) Consultant

( ) Other (please describe):

7) From July 1, 2022, through June 30, 2023, were any of your immediate family member(s) employed by a Trinity Health organization(s)?

Immediate family members include your spouse, children, grandchildren, great-grandchildren, siblings (whether whole or half-blood), parents, grandparents, great-grandparents, and spouses of your siblings, children, grandchildren, and great grandchildren. Family relationships include relationships by birth and by adoption.

( ) Yes ( ) No

Provide the full name of the family member(s) employed by a Trinity Health organization(s):

Describe the family member’s relationship to you:

Trinity Health organization(s) which employs your family member(s) (list all that apply):

8) From July 1, 2022, through June 30, 2023, to the best of your knowledge, did any members of your immediate family (as defined in Question 7), personally or through a company with which they have an ownership, employment, management, consulting or board relationship, provide products or services to, have an outstanding loan to/from, or receive grants, scholarships or other assistance from a Trinity Health organization(s), or otherwise conduct a business transaction with a Trinity Health organization(s)?

( ) Yes ( ) No

Provide the full name of family member(s):

Describe the family member’s relationship to you:

Provide the name of the company with a relationship to your family member:

Indicate your immediate family member’s relationship to the company (select one):

( ) Board member

( ) Employee

( ) Consultant

( ) Other (please describe):

Provide a brief description of the products, services, and/or business transaction conducted with Trinity Health organization(s):

Indicate the Trinity Health organization(s) involved (list all that apply):

9) From July 1, 2022, through June 30, 2023, did you have a family or business relationship(s) with any other officer, director, trustee, executive or key employee of Trinity Health?

NOTE: Business relationships include employment, conducting business transactions in excess of $10,000, serving as a director, trustee, officer or owner in a business involving any other officer, director, trustee, executive or key employee of Trinity Health.

( ) Yes ( ) No

Provide the full name (first, middle, last) of the Trinity Health officer, director, trustee, executive or key employee with which you had a family or business relationship:

Indicate the type of relationship as one of the following (select one):

( ) Family relationship

( ) Business relationship

Trinity Health organization(s) that employs this Trinity Health officer, director, trustee, executive or key employee:

10) From July 1, 2022, through June 30, 2023, did you receive, directly or indirectly, any personal benefits (including gifts or awards) from a Trinity Health organization(s) as a result of your relationship with Trinity Health that in the aggregate would be valued in excess of $1,000 and was not or will not be reported as compensation directly related to your duties to Trinity Health?

NOTE: Reimbursement of normal travel and other business-related expenses by Trinity Health do not require reporting.

( ) Yes ( ) No

Provide a description of personal benefit (including gifts or awards) received:

Provide an estimated dollar value (rounded to the nearest dollar) of this personal benefit received, excluding compensation:

$__________

Trinity Health organization(s) that provided you with this personal benefit:

11) To the best of your knowledge, are you aware of any events, transactions, or arrangements involving instances of fraud or the material diversion of Trinity Health assets that occurred during Fiscal Year 2023 or that may occur in the future, including pending or contemplated transactions or arrangements, you believe should be examined by Trinity Health’s Board of Directors?

( ) Yes ( ) No

Provide an explanation of the event, transaction, or other arrangement that you believe should be reviewed:

Trinity Health organization(s) involved in this event, transaction, or other arrangement:

Trinity Health is required to ask the following question of all Officers, Directors and Managing Employees (as defined) of an enrolled health care provider participating in Federal and State health care programs.

See Exhibit on last page for a description of Medicare reportable Final Adverse Legal Action.

12) To the best of your knowledge, within the last ten (10) years have you, under your name or under any current or former business identity, ever had a Medicare reportable Final Adverse Legal Action imposed against you?

( ) Yes ( ) No

Provide a description of the Final Adverse Legal Action:

Provide the date of the Final Adverse Legal Action:

Provide the name of the federal or state agency:

Provide a description of the resolution:

Trinity Health is required to ask the following question of all Officers, Directors and Managing Employees (as defined) of an enrolled health care provider participating in federal and state health care programs.

• A financial interest or affiliation may include:

• A 5% or greater ownership interest (direct or indirect);

• A general or limited partnership interest (regardless of the percentage);

• Acting as an officer or director; and/or

• An interest (direct or indirect) in which you exercised operational or managerial control over the day-to-day operations.

See Exhibit on last page for a list of example providers and suppliers -

13) In the previous five (5) years, other than your affiliation with Trinity Health, have you held any financial interest or affiliation with another provider or supplier enrolled in or billing the Medicare, Medicaid or Children’s Health Insurance Program (CHIP)?

( ) Yes ( ) No

14) Do you currently serve or otherwise participate in any Outside Material Activities not previously disclosed herein?

Outside Material Activities include: service as a director, trustee, officer, committee member, employee, independent contractor, consultant, or an agent in a similar position with another organization (regardless of whether the organization is charitable or for-profit in nature).*

( ) Yes ( ) No

Provide a brief description of the Outside Material Activity, including name of company or organization, term of service or relationship, and approximate time commitment:

Do you have any additional items to report under Question 14?*

( ) Yes ( ) No

Provide a brief description of the Outside Material Activity, including name of company or organization, term of service or relationship, and approximate time commitment:*