WHol- $0as'7S- 345p00
State Consultant Services OSC Use Only
Reporting Code:
FORM A Catan cece
Date Contract Approved:
Contractor's Planned Employment
From Contract Start Date through End of Contract Term
New York State Department of Health Agency Code 12000
Contractor Name: Elisabeth C. Zausmer, MD Contract Number: S-028775
Contract Start Date: 4/1/13 Contract End Date: 12/31/17
Employment Category Number of | Number of Amount Payable
Employees — Hours to be Under the
Worked Contract
Physicians and Surgeons SELF 5,066.66 $304,000.00
[ t
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Totals this page: 0 5,066.66 $304,000.00 |
Grand Total: O° 5,066.66 $304,000.00
Name of person who prepared this report: Elisabeth C. Zausmer, MD
Phone #:( 716 )472-9748
Preparer’s signature:
Date Prepared: 13, Page 1 of 1
(use additional pages if necessary)
Page 1 of 1