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2021 Annual Hospital QuestionnairePart A : General Information1. IdentificationUID:hosp634Facility Name: Northside HospitalCounty: FultonStreet Address: 1000 Johnson Ferry Road NECity: AtlantaZip: 30342-1611Mailing Address: 1000 Johnson Ferry Road NEMailing City: AtlantaMailing Zip: 30342-1611Medicaid Provider Number: 00001405Medicare Provider Number: 1101612. Report PeriodReport Data for the full twelve month period- January 1, 2021 through December 31, 2021.Do not use a different report period.Check the box to the right if your facility was not operational for the entire year.If your facility was not operational for the entire year, provide the dates the facility was operational.Part B : Survey Contact InformationPerson authorized to respond to inquiries about the responses to this survey.Contact Name: Brian J. ToporekContact Title: Senior PlannerPhone: 404-851-6821Fax: 404-250-3102E-mail: brian.toporek@northside.comPage 1
Part C : Ownership, Operation and Management1. Ownership, Operation and ManagementAs of the last day of the report period, indicate the operation/management status of the facility andprovide the effective date. Using the drop-down menus, select the organization type. If the categoryis not applicable, the form requires you only to enter Not Applicable in the legal name field. Youmust enter something for each category.A. Facility OwnerFull Legal Name (Or Not Applicable)Organization TypeHospital Authority of Fulton CountyEffective DateHospital AuthorityB. Owner's Parent OrganizationFull Legal Name (Or Not Applicable)Organization TypeN/A7/1/1970Effective DateNot ApplicableC. Facility OperatorFull Legal Name (Or Not Applicable)Organization TypeNorthside Hospital, Inc.Effective DateNot for ProfitD. Operator's Parent OrganizationFull Legal Name (Or Not Applicable)Organization TypeNorthside Health Services, Inc.11/1/1991Effective DateNot for ProfitE. Management ContractorFull Legal Name (Or Not Applicable)Organization TypeN/A11/1/1991Effective DateNot ApplicableF. Management's Parent OrganizationFull Legal Name (Or Not Applicable)Organization TypeN/AEffective DateNot Applicable2. Changes in Ownership, Operation or ManagementCheck the box to the right if there were any changes in the ownership, operation, or management ofthe facility during the report period or since the last day of the Report Period.If checked, please explain in the box below and include effective dates.3. Check the box to the right if your facility is part of a health care systemName: Northside Hospital, Inc.City: Atlanta State: Georgia4. Check the box to the right if your hospital is a division or subsidiary of a holding company.Name: Northside Health Services, Inc.City: Atlanta State: GAPage 2
5. Check the box to the right if the hospital itself operates subsidiary corporationsName:City:State:6. Check the box to the right if your hospital is a member of an alliance.Name: Ga Alliance of Community Hospitals, VHACity:State:7. Check the box to the right if your hospital is a participant in a health care networkName: Northside Health Network; NovaNet; othersCity:State:8. Check the box to the right if the hospital has a policy or policies and a peer review process relatedto medical errors.9. Check the box to the right if the hospital owns or operates a primary care physician grouppractice.10a. Managed Care Information: Formal Written ContractDoes the hospital have a formal written contract that specifies the obligations of each party witheach of the following? (check the appropriate boxes)1. Health Maintenance Organization(HMO)2. Preferred Provider Organization(PPO)3. Physician Hospital Organization(PH0)4. Provider Service Organization(PSO)5. Other Managed Care or Prepaid Plan10b. Managed Care Information: Insurance ProductsCheck the appropriate boxes to indicate if any of the following insurance products have beendeveloped by the hospital, health care system, network, or as a joint venture with an insurer:Type of Insurance ProductHospitalHealth Care SystemNetworkJoint Venture with InsurerHealth Maintenance OrganizationPreferred Provider OrganizationIndemnity Fee-for-Service PlanAnother Insurance Product NotListed Above11. Owner or Owner Parent Based in Another StateIf the owner or owner parent at Part C, Question 1(A&B) is an entity based in another state pleasereport the location in which the entity is based. (City and State)Page 3
Part D : Inpatient Services1. Utilization of Beds as Set Up and Staffed(SUS):Please indicate the following information. Dod not include newborn and neonatal services. Do notinclude long-term care untits, such as Skilled Nursing Facility beds, if not licensed as hospital beds.If your facility is approved for LTCH beds report them below.CategoryObstetrics (no GYN,SUS BedsAdmissionsInpatient DaysDischargesDischarge Days16216,48056,10116,50956,213Pediatrics (Non ICU)00000Pediatric ICU00000278292,6728312,659General Medicine00000General nce Abuse00000Adult Physical0000000000Burn Care00000Swing Bed (Include 162,508include LDRP)Gynecology (No OB)Intensive CareRehabilitation (18 &Up)Pediatric PhysicalRehabilitation (0-17)Utilization)Long Term CareHospital (LTCH)TotalPage 4
2. Race/EthnicityPlease report admissions and inpatient days for the hospital by the following race and ethnicitycategories. Exclude newborn and neonatal.Race/EthnicityAdmissionsAmerican Indian/Alaska NativeInpatient Days93685Asian1,8368,329Black/African 2,91568,5121,66710,04932,022163,823Pacific Islander/HawaiianWhiteMulti-RacialTotal3. GenderPlease report admissions and inpatient days by gender. Exclude newborn and neonatal.GenderAdmissionsMaleInpatient 234. Payment SourcePlease report admissions and inpatient days by primary payment source. Exclude newborn andneonatal.Primary Payment SourceAdmissionsInpatient ayOther5. Discharges to DeathReport the total number of inpatient admissions discharged during the reporting period due to death.4586. Charges for Selected ServicesPlease report the hospital's average charges as of 12-31-2021 (to the nearest whole dollar).ServiceChargePrivate Room Rate1,602Semi-Private Room Rate0Operating Room: Average Charge for the First Hour10,760Average Total Charge for an Inpatient Day13,689Page 5
Part E : Emergency Department and Outpatient Services1. Emergency VisitsPlease report the number of emergency visits only.53,7822. Inpatient Admissions from ERPlease report inpatient admssions to the Hospital from the ER for emergency cases ONLY.10,5693. Beds AvailablePlease report the number of beds available in ER as of the last day of the report period.484. Utilization by Specific type of ER bed or room for the report period.Type of ER Bed or RoomBedsVisitsBeds dedicated for Trauma00Beds or Rooms dedicated for Psychiatric /Substance Abuse cases00General Beds004264,35162,1970000Multipurpose BedsBehavioral Health (seen in multipurpose rm 1st)5. TransfersPlease provide the number of Transfers to another institution from the Emergency Department.1,1616. Non-Emergency VisitsPlease provide the number of Outpatient/Clinic/All Other Non-Emergency visits to the hospital.751,2777. Observation Visits/CasesPlease provide the total number of Observation visits/cases for the entire report period.8,3078. Diverted CasesPlease provide the number of cases your ED diverted while on Ambulance Diversion for the entirereport period.09. Ambulance Diversion HoursPlease provide the total number of Ambulance Diversion hours for your ED for the entire reportperiod2,042.00Page 6
10. Untreated CasesPlease provide the number of patients who sought care in your ED but who left without or beforebeing treated. Do not include patients who were transferred or cases that were diverted.946Part F : Services and Facilities1a. Services and FacilitiesPlease report services offered onsite for in-house and contract services as requested. Please reflectthe status of the service during the report period. (Use the blank lines to specify other services.)Site Codes1 In-House - Provided by the Hospital2 Contract - Provided by a contractor but onsite3 Not ApplicableStatus Codes1 On-Going2 Newly Initiated3 Discontinued4 Not ApplicableService/FacilitiesSite CodeService StatusPodatric Services11Renal Dialysis11ESWL21Billiary Lithotropter34Kidney Transplants34Heart Transplants34Other-Organ/Tissues Transplants11Diagnostic X-Ray11Computerized Tomography Scanner (CTS)11Radioisotope, Diagnositic11Positron Emission Tomography (PET)11Radioisotope, Therapeutic11Magnetic Resonance Imaging (MRI)11Chemotherapy11Respiratory Therapy11Occupational Therapy11Physical Therapy11Speech Pathology Therapy11Gamma Ray Knife34Audiology Services11HIV/AIDS Diagnostic Treatment/Services34Ambulance Services34Hospice34Respite Care Services34Ultrasound/Medical Sonography11000000Page 7
1b. Report Period Workload TotalsPlease report the workload totals for in-house and contract services as requested. The number ofunits should equal the number of machines.CategoryTotalNumber of Podiatric Patients665Number of Dialysis Treatments2,941Number of ESWL Patients110Number of ESWL Procedures110Number of ESWL Units2Number of Biliary Lithotripter Procedures0Number of Biliary Lithotripter Units0Number of Kidney Transplants0Number of Heart Transplants0Number of Other-Organ/Tissues Treatments207Number of Diagnostic X-Ray Procedures107,905Number of CTS Units (machines)28Number of CTS Procedures75,964Number of Diagnostic Radioisotope Procedures4,088Number of PET Units (machines)5Number of PET Procedures2,423Number of Therapeautic Radioisotope Procedures77Number of Number of MRI Units32Number of Number of MRI Procedures42,475Number of Chemotherapy Treatments63,352Number of Respiratory Therapy Treatments94,230Number of Occupational Therapy Treatments60,642Number of Physical Therapy Treatments91,477Number of Speech Pathology Patients3,672Number of Gamma Ray Knife Procedures0Number of Gamma Ray Knife Units0Number of Audiology Patients15,942Number of HIV/AIDS Diagnostic Procedures0Number of HIV/AIDS Patients0Number of Ambulance Trips0Number of Hospice Patients0Number of Respite care Patients0Number of Ultrasound/Medical Sonography Units40Number of Ultrasound/Medical Sonography Procedures48,248Number of Treatments, Procedures, or Patients (Other 1)0Number of Treatments, Procedures, or Patients (Other 2)0Number of Treatments, Procedures, or Patients (Other 3)02. Medical VentilatorsProvide the number of computerized/mechanical Ventilator Machines that were in use or availablePage 8
for immediate use as of the last day of the report period (12/31).1453. Robotic Surgery SystemPlease report the number of units, number of procedures, and type of unit(s).# Units# Procedures8Type of Unit(s)3,393 8 da Vinci Xi SystemsPage 9
Part G : Facility Workforce Information1. Budgeted StaffPlease report the number of budgeted fulltime equivalents (FTEs) and the number of vacancies asof 12-31-2021. Also, include the number of contract or temporary staff (eg. agency nurses) fillingbudgeted vacancies as of nLicensed Physicians88.4011.3039.71Physician Assistants Only (not including23.483.280.002,639.42339.612.17Licensed Practical Nurses r Health Services Professionals*1,459.56200.61157.50Administration and Support3,566.80355.532.42579.660.0026.32Licensed Physicians)Registered Nurses (RNs-Advanced Practice*)All Other Hospital Personnel (not includedabove)2. Filling VacanciesUsing the drop-down menus, please select the average time needed during the past six months tofill each type of vacant position.Type of VacancyAverage Time Needed to Fill VacanciesPhysician's Assistants31-60 DaysRegistered Nurses (RNs-Advance Practice)61-90 DaysLicensed Practical Nurses (LPNs)31-60 DaysPharmacists31-60 DaysOther Health Services Professionals31-60 DaysAll Other Hospital Personnel (not included above)31-60 Days3. Race/Ethnicity of PhysiciansPlease report the number of physicians with admitting privileges by race.Race/EthnicityNumber of PhysiciansAmerican Indian/Alaska Native0Asian0Black/African American0Hispanic/Latino0Pacific Islander/Hawaiian0White0Multi-Racial04. Medical StaffPlease report the number of active and associate/provisional medical staff for the following specialtycategories. Keep in mind that physicians may be counted in more than one specialty. PleasePage 10
indicate whether the specialty group(s) is hospital-based. Also, indicate how many of each medicalspecialty are enrolled as providers in Georgia Medicaid/PeachCare for Kids and/or the PublicEmployee Health Benefit Plans (PEHB-State Health Benefit Plant and/or Board of Regents BenefitPlan).Medical SpecialtiesGeneral and FamilyNumber ofCheck if AnyNumber Enrolled as Providers inNumber Enrolled asMedical Staffare Hospital BasedMedicaid/PeachCareProviders in PEHB Plan17200General Internal Medicine42600Pediatricians22800Other Medical Specialties64700PracticeSurgical SpecialtiesObstetricsNumber ofCheck if AnyNumber Enrolled as Providers inNumber Enrolled asMedical Staffare Hospital BasedMedicaid/PeachCareProviders in PEHB Plan238000007800Ophthalmology Surgery11600Orthopedic Surgery169008300General Surgery10800Thoracic Surgery60033400Non-OB PhysiciansProviding OB ServicesGynecologyPlastic SurgeryOther Surgical SpecialtiesOther SpecialtiesAnesthesiologyNumber ofCheck if AnyNumber Enrolled as Providers inNumber Enrolled asMedical Staffare Hospital BasedMedicaid/PeachCareProviders in PEHB Plan12600340012900Nuclear 7002400000000DermatologyEmergency MedicineRadiation OncologyPage 11
5a. Non-PhysiciansPlease report the number of professionals for the categories below. Exclude any hospital-basedstaff reported in Part G, Questions 1,2,3 and 4 above.ProfessionNumberDentists (include oral surgeions) with Admitting130PrivlegesPodiatrists47Certified Nurse Midwives with Clinical Privileges in the89HospitalAll Other Staff Affiliates with Clinical Privileges in the1,366Hospital5b. Name of Other ProfessionsPlease provide the names of professions classified as "Other Staff Affiliates with Clinical Privileges"above.physicians assistant, nurse practitioner, anesthesiology assistants, nurse anesthetist, clinicalpsychologist, optometristComments and Suggestions:Page 12
Part H : Physician Name and License Number1. Physicians on StaffPlease report the full name and license number of each physician on staff. (Due to the largenumber of entries, this section has been moved to a separate PDF file.)Part I : Patient Origin Table1. Patient OriginPlease report the county of origin for the inpatient admissions or discharges excluding newborns(except surgical services should include outpatients only).Inpat Inpatient ServicesSurg Outpatient SurgicalOB ObstetricP18 Acute psychiatric adult 18 and overP13-17 Acute psychiatric adolescent 13-17P0-12 Acute psychiatric children 12 and underRehab Inpatient RehabilitationCountyAlabamaInpatSurgS18 Substance abuse adult 18 and overS13-17 Substance abuse adolescent 13-17E18 Extended care adult 18 and overE13-17 Extended care adolescent 13-17E0-12 Extended care children 0-12LTCH Long Term Care HospitalOBP18 P13-17P0-12S18 S13-17E18 artow117128430000000000Ben rollClarkePage 13
hamHallHoustonPage 14
0Jeff orth 0000000Other Out Of iercePage 15
Rockdale2452029900000000001010000000000South nnesseeTownsTreutlenPage 16
Surgical Services AddendumPart A : Surgical Services Utilization1. Surgery Rooms in the OR SuitePlease report the Number of Surgery Rooms, (as of the end of the report period). Report only therooms in CON-Approved Operating Room Suites pursuant to Rule 111-2-2-.40 and 111-8-48-.28.Room TypeDedicated Inpatient RoomsDedicated Outpatient RoomsShared RoomsGeneral Operating02030Cystoscopy (OR Suite)000Endoscopy (OR Suite)00000002030Total2. Procedures by Type of RoomPlease report the number of procedures by type of room.Room TypeDedicatedDedicatedSharedSharedInpatient RoomsOutpatient RoomsInpatient RoomsOutpatient RoomsGeneral y00000000022,29219,63437,838Total3. Patients by Type of RoomPlease report the number of patients by type of room.Room TypeDedicatedDedicatedSharedSharedInpatient RoomsOutpatient RoomsInpatient RoomsOutpatient RoomsGeneral 000000009,9805,06214,835TotalPart B : Ambulatory Patient Race/Ethnicity, Age, Gender and Payment Source1. Race/Ethnicity of Ambulatory PatientsPlease report the total number of ambulatory patients for both dedicated outpatient and shared roomenvironment.Page 17
Race/EthnicityNumber of Ambulatory PatientsAmerican Indian/Alaska Native65Asian857Black/African American6,369Hispanic/Latino1,503Pacific al24,8152. Age GroupingPlease report the total number of ambulatory patients by age grouping.Age of PatientNumber of Ambulatory PatientsAges 0-1462Ages 15-6416,971Ages 65-745,241Ages 75-852,208Ages 85 and Up333Total24,8153. GenderPlease report the total number of ambulatory patients by gender.GenderNumber of Ambulatory PatientsMale7,606Female17,209Total24,8154. Payment SourcePlease report the total number of ambulatory patients by payment source.Primary Payment SourceNumber of y13,7262,772Perinatal Services AddendumPart A : Obstetrical Services UtilizationPlease report the following obstetrical services information for the report period. Include all deliveriesand births in any unit of th hospital or anywhere on its grounds.1. Number of Delivery Rooms: 6Page 18
2. Number of Birthing Rooms: 03. Number of LDR Rooms: 424. Number of LDRP Rooms: 05. Number of Cesarean Sections: 6,3136. Total Live Births: 15,3577. Total Births (Live and Late Fetal Deaths): 15,5108. Total Deliveries (Births Early Fetal Deaths and Induced Terminations): 16,696Part B : Newborn and Neonatal Nursery Services1. Nursery ServicesPlease Report the following newborn and neonatal nursery information for the report period.Type of NurseryNormal NewbornSet-Up and sionsDayswithin 95124(Basic)Specialty Care(Intermediate Neonatal Care)Subspecialty Care(Intensive Neonatal Care)Part C : Obstetrical Charges and Utilization by Mother's Race/Ethnicity and Age1. Race/EthnicityPlease provide the number of admissions and inpatient days for mothers by the mother's race usingrace/ethnicity classifications.Race/EthnicityAdmissions by Mother's RaceAmerican Indian/Alaska NativeInpatient Days51177Asian1,3494,495Black/African 10616,4867532,71516,48056,101Pacific Islander/HawaiianWhiteMulti-RacialTotalPage 19
2. Age GroupingPlease provide the number of admissions by the following age groupings.Age of PatientNumber of AdmissionsAges 0-14Ages 15-44Ages 45 and UpTotalInpatient Days82316,40955,8326324616,48056,1013. Average Charge for an Uncomplicated DeliveryPlease report the average hospital charge for an uncomplicated delivery(CPT 59400) 13,784.004. Average Charge for a Premature DeliveryPlease report the average hospital charge for a premature delivery. 45,978.00LTCH AddendumPart A : General Information1a. Accreditation Check the box to the right if your Long Term Care Hospital is accredited.If you checked the box for yes, please specify the agency that accredits your facility in the spacebelow.1b. Level/Status of AccreditationPlease provide your organization's level/status of accreditation.2. Number of Licensed LTCH Beds: 03. Permit Effective Date:4. Permit Designation:5. Number of CON Beds: 06. Number of SUS Beds: 07. Total Patient Days: 08. Total Discharges: 09. Total LTCH Admissions: 0Part B : Utilization by Race, Age, Gender and Payment Source1. Race/EthnicityPlease provide the number of admissions and inpatient days using the following race/ethnicityclassifications.Page 20
Race/EthnicityAdmissionsAmerican Indian/AlaskaInpatient Days00Asian00Black/African American00Hispanic/Latino00Pacific ive2. Age of LTCH PatientPlease provide the number of admissions and inpatient days by the following age groupings.Age of PatientAdmissionsInpatient DaysAges 0-6400Ages 65-7400Ages 75-8400Ages 85 and Up00Total003. GenderPlease provide the number of admissions and inpatient days by the following gender classifications.Gender of PatientAdmissionsInpatient DaysMale00Female00Total004. Payment SourcePlease indicate the number of patients by the payment source. Please note that individuals mayhave multiple payment sources.Primary Payment SourceNumber of PatientsInpatient atric/Substance Abuse Services AddendumPart A : Psychiatric and Substance Abuse Data by ProgramPage 21
1. BedsPlease report the number of beds as of the last day of the report period. Report beds only forofficially recognized programs. Use the blank row to report combined beds. For combined bedprograms, please report each of the combined bed programs and the number of combined beds.Indicate the combined programs using letters A through H, for example,"AB"Patient TypeDistribution of CON-Authorized BedsSet-Up and Staffed BedsA- General Acute Psychiatric Adults 18 and over00B- General Acute Psychiatric Adolescents 13-1700C- General Acute Psychiatric Children 12 and00D- Acute Substance Abuse Adults 18 and over00E- Acute Substance Abuse Adolescents 13-1700F-Extended Care Adults 18 and over00G- Extended Care Adolescents 13-1700H- Extended Care Adolescents 0-120000under2. Admissions, Days, Discharges, AccreditationPlease report the following utilization for the report period. Report only for officially recognizedprograms.Program TypeAdmissionsInpatientDischargesDaysGeneral AcuteDischargeAverage ChargeCheck if the ProgramDaysPer Patient Dayis JCAHO Psychiatric Adults 18and overGeneral AcutePsychiatricAdolescents 13-17General AcutePsychiatric Children 12and UnderAcute SubstanceAbuse Adults 18 andoverAcute SubstanceAbuse Adolescents13-17Extended Care Adults18 and overExtended CareAdolescents 13-17Extended CareAdolescents 0-12Page 22
Part B : Psych/SA Utilization by Race/Ethnicity, Gender, and Payment Source1. Race/EthnicityPlease provide the number of admissions and inpatient days using the following ionsAmerican Indian/AlaskaInpatient Days00Asian00Black/African American00Hispanic/Latino00Pacific ive2. GenderPlease provide the number of admissions and inpatient days by the following gender classifications.Gender of PatientAdmissionsInpatient DaysMale00Female00Total003. Payment SourcePlease indicate the number of patients by the following payment sources. Please note thatindividuals may have multiple payment sources.Primary Payment SourceNumber of PatientsInpatient DaysMedicare00Medicaid00Third Party00Self-Pay00PeachCare00Page 23
Georgia Minority Health Advisory Council AddendumBecause of Georgia’s racial and ethnic diversity, and a dramatic increase in segments of the population withLimited English Proficiency, the Georgia Minority Health Advisory Council is working with the Department ofCommunity Health to assess our health systems’ ability to provide Culturally and Linguistically AppropriateServices (CLAS) to all segments of our population. We appreciate your willingness to provide information onthe following questions:1. Do you have paid medical interpreters on staff? (Check the box, if yes.)If you checked yes, how many? 13 (FTE's)What languages do they interpret?Spanish, Russian, Vietnamese, Korean, Chinese2. When a paid medical interpreter is not available for a limited-English proficiency patient, whatalternative mechanisms do you use to assure the provision of Linguistically Appropriate Services?(Check all that apply)Bilingual Hospital Staff MemberBilingual Member of Patient's FamilyCommunity Volunteer IntrepreterTelephone Interpreter ServiceRefer Patient to Outside AgencyOther (please describe):video remote iPads; Agency interpreters3. Please complete the following grid to show the proportion of patients you serve who preferspeaking various languages (name the 3 most common non-English languages spoken.)Top 3 most commonPercent of patients for# of physicians on# of nurses on# of othernon-English languageswhom this is theirstaff who speakstaff who speakemployed staff whospoken by your patientspreferred languagethis languagethis languagespeak this .070004. What training have you provided to your staff to assure cultural competency and the provision ofCulturally and Linguistically Appropriate Services (CLAS) to your patients?All new hired staff must complete a computer-based training/learning course (CBL). In-servicePage 24
training is provided throughout the organization. All interpreters must complete annual mandatoryCBL on cultural and complete competencies. Language Census Report is generated automaticallytwice a day in every nursing unit. Interpreters do daily rounds on all limited English proficientpatients.5. What is the most urgent tool or resource you need in order to increase your ability to provideCulturally and Linguistically Appropriate Services (CLAS) to your patients?6. In what languages are the signs written that direct patients within your facility?1. English2. Spanish3.4.7. If an uninsured patient visits your emergency department, is there a community health center,federally-qualified health center, free clinic, or other reduced-fee safety net clinic nearby to whichyou could refer that patient in order to provide him or her an affordable primary care medical homeregardless of ability to pay? (Check the box, if yes)If you checked yes, what is the name and location of that health care center or clinic?Page 25
Comprehensive Inpatient Physical Rehabilitation AddendumPart A : Rehab Utilization by Race/Ethnicity, Gender, and Payment Source1. Admissions and Days of Care by RacePlease report the number of inpatient physical rehabilitation admissions and inpatient days for thehospital by the following race and ethnicity categories.Race/EthnicityAdmissionsInpatient DaysAmerican Indian/Alaska Native00Asian00Black/African American00Hispanic/Latino00Pacific Islander/Hawaiian00White00Multi-Racial002. Admissions and Da
Full Legal Name (Or Not Applicable) Organization Type Effective Date Northside Health Services, Inc. Not for Profit 11/1/1991 E. Management Contractor Full Legal Name (Or Not Applicable) Organization Type Effective Date N/A Not Applicable F. Management's Parent Organization Full Legal Name (Or Not Applicable) Organization Type Effective Date
