If additional space is needed, please continue on a separate page using the same format. a. b. c. Name & degree Place of employment Will this person be obtaining verbal or written Informed Consent/Authorization SUNY Downstate Yes No NYC H+H, County Other: SUNY Downstate Yes No NYC H+H, County Other: SUNY Downstate Yes No NYC H+H, Kings County Other: SUNY Downstate Yes No NYC H+H, Kings County SUNY Downstate Yes No NYC H+H, Kings County Other: SUNY Downstate Yes No NYC H+H, Kings County SUNY Downstate Yes No NYC H+H, Kings County Other: SUNY Downstate Yes No NYC H+H, Kings County Other: Attach additional if needed.
If additional space is needed, please continue on a separate page using the same format. a. Name & degree b. Place of employment c. Will this person be obtaining verbal or written Informed Consent/Authorization SUNY Downstate NYC H+H, County Other: Yes No SUNY Downstate NYC H+H, County Other: Yes No SUNY Downstate NYC H+H, Kings County Other: Yes No SUNY Downstate NYC H+H, Kings County Yes No SUNY Downstate NYC H+H, Kings County Other: Yes No SUNY Downstate NYC H+H, Kings County Yes No SUNY Downstate NYC H+H, Kings County Other: Yes No SUNY Downstate NYC H+H, Kings County Other: Yes No Attach additional if needed.
ApplicationforProgressReportforHUDforClinicalUseONLY04.28.2017.docx