If additional space is needed, please continue on a separate page using the same format. a. b. c. d. Name & degree Place of employment Will this person be Does the clinician have or declare REMINDER: is required for NYC H obtaining verbal or a Conflict of Interest (COI), + H, KC written Informed including the participation in the Consent/Authorization product design or development of this device, or as a company directory or consultant? If yes, submit COI disclosures. SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other: SUNY Downstate Yes No Yes No H + H, NYC KC Other:
If additional space is needed, please continue on a separate page using the same format. a. Name & degree b. Place of employment REMINDER: is required for NYC H + H, KC c. Will this person be obtaining verbal or written Informed Consent/Authorization d. Does the clinician have or declare a Conflict of Interest (COI), including the participation in the product design or development of this device, or as a company directory or consultant? If yes, submit COI disclosures. SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No
ApplicationforHUDforClinicalUse12.19.2018.docx