ࡱ> O 4"bjbjgQgQ 42;e;e4=====QQQQ$uQ F#^=====hqe8iF 0#&#,#=D# :  AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION TO NEWS MEDIA AND TO THE GENERAL PUBLIC We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before using or disclosing your protected health information to communicate with the news media and the general public, as described below. This form provides that authorization and helps us ensure that you are appropriately informed of how this information will be used or disclosed. Please read the information below carefully before signing this form. A ĢƵ representative is available to answer any questions regarding this authorization. Patient Name: _____________________________________ MR#: ______________________ Address: ____________________________________________________________________ ____________________________________________________________________ DOB: _______________ Telephone #: __________________ (Day) _______________ (Eve) I consent that a statement/interview, or photograph, and/or illustration, and/or video, and/or movie, and/or audiorecording may be taken of me and/or my child by ĢƵ (and/or its agents) or by members of the news media regarding my personal and medical history, condition(s), and treatment(s) to publicize, promote, marketing, or advertising ĢƵs activities, programs, and services. I grant permission for the above-described material(s), which may include Protected Health Information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA), to be used by news media, including professional medical or healthcare journals, for publication and/or broadcast, and/or distribution via other means to the general public, including the Internet, social media, and mobile telephone applications or future technologies, not excluding its use at professional meetings, symposiums, poster sessions or other events. I recognize that the precise manner in which the information and material(s) may be used will be determined solely by the media described above and I, therefore, acknowledge that ĢƵ has no control over or responsibility for the use of such information and material(s). I further grant permission for SUNY Downstate, at its option, to use the information and material(s) as it sees fit in publications and or productions of its own making and distribution, including on the SUNY Downstate website ( HYPERLINK "http://www.downstate.edu" www.downstate.edu) and digital monitors throughout SUNY Downstate facilities. Person(s)/ Organizations at SUNY Downstate providing the information: _______________________________ The information may be disclosed to and used by the (name of media outlet) ____________________________ Information to be disclosed: ___________________________________________________________________ I understand that I/my child may be identified by name in connection with the public use of the information and material(s). I hereby release and agree to indemnify SUNY Downstate and its affiliates, successors, and assignees and their respective employees, trustees, and agents from and against any and all liability, including reasonable attorneys fees, arising out of the exercise of the rights granted by this authorization. I understand that SUNY Downstate __ will __ will not receive direct or indirect remuneration due to this authorization. This authorization expires on ____________________________________________. I understand that the expiration of this authorization will not cause the news described above coverage or promotional, marketing, or advertising materials made as a result of this authorization to be withdrawn from public circulation at the time of expiration or any time thereafter. New York State regulations [ NY Public Health Law 2782(1)(b) ] require a special authorization for release of information regarding mental health, any HIV- related condition (including HIV-related test, illness, AIDS or any information indicating potential exposure to HIV) or drug and alcohol abuse. __ DO NOT authorize the release of this information. __ DO authorize the release of this information. By signing this authorization form, you authorize the use or disclosure of your protected health information, as described above. This information may be re-disclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information. If you are authorizing the release of HIV-related information, you should be aware that the recipient(s) is prohibited from re-disclosing any HIV-related information without your authorization unless permitted to do so under federal or state law. If you experience discrimination because of the release of disclosure of HIV-related information, you may contact the New York State Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights. You have a right to refuse to sign this authorization. However, your healthcare, the payment for your healthcare, and your healthcare benefits will not be affected if you do not sign this form. You have a right to receive a copy of this form after signing it. You have the right to revoke this authorization at any time, except to the extent that action has already been taken based upon your approval. To withdraw this authorization, please write to: ĢƵ Office of Communications & Marketing, Box 2 450 Clarkson Ave., Brooklyn, NY 11203 Signature: _____________________________________________________ Date: ____________________________ (Participant, Personal Representative or Legal Guardian) Witness: ____________________________________ Print Name: ________________________________________ Personal Representative or Legal Guardian: [Print Name] ________________________________________________ Authority: ______________________________________________ Telephone: __________________________ E-mail: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ QUf= P    P W p q r s  s y ' 7 : c <cʿʴʿʴʴʴʮxnxh,CJOJQJhs+CJOJQJh5UCJOJQJh RCJOJQJhowCJOJQJ^Jh RCJOJQJ^J h R^Jh[c6CJ]^Jh,6CJ]^Jh R6CJ]^Jh[c5>*CJ\^Jh R5>*CJ\^Jh RCJOJQJjh[cU)ef  h A cd^ $gdowgdow  ^gdowdh  $dhgdow$a$gdow$a$$a$gd[ccd&$6_qxU]gz:;rsCOw}*޼޼觡|h^CJOJQJheCJOJQJh[cCJOJQJ h R6CJ howCJ h RCJhQ%h5U0JCJOJQJjh5UCJOJQJUhs+CJOJQJh,CJOJQJh5UCJOJQJh RCJOJQJh RCJOJQJ]^J0^g,S$a$$h]^h`a$$]^`a$gdowgdow$a$gdow  ^gdowdhgdow*><=t~7>BC-8FRZmŶzkkh5U6CJOJQJ]^Jhs+6CJOJQJ]^Jh[c6CJOJQJ]^Jhow6CJOJQJ]^Jh,6CJOJQJ]^Jh R6CJOJQJ]^Jh ROJQJ h,CJ howCJ h RCJh RCJOJQJ]^Jh RCJOJQJh,CJOJQJ*<=.Z* + , !h!i!!!4"$]^`a$gdow$]a$gd5U$a$m M!T!h!q!r!!!!,"3"4"h5Uh ROJQJh5UOJQJhowOJQJh ROJQJ"h5Uh R6CJOJQJ]^J21h:pow/ =!"#$% Dd e%N^]6  3 AbSQc"bH֍D_n΍SQc"bHPNG  IHDRfr pHYs  ~ IDATxq׵7KUs tC8P# F`pDT}H`p9Wj[ D`cyX==3?_~Z%-"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZ( @kE5"К@hM&PZR0g77ݬb+@kE5"К@hM&PZ( @kE5"К@hM&PZRn_,cXNy%|nnl\ S&PZ( @kE5"К@hM&PZ( @kE5"h\hi\x`7E3k̍@hM&PZ(`!i~ik|nf} z@U n{>iĵI3"tuvCTeőxaP@v:O}M\ ~P{_qʨ>)yag8Nl?/xY>ס(-GZw |A< e`e<EA .*ƿ{1_fa( P@I!U4oG4lCE: f(S0ت9󁆉C 5ݥ/%v> 7Aq3hlн0X{1@hϓvm ]?P`rfkGzwGsm?nτd8~JVpN9H`ZnQu;X[BvfP=ޒ)U>@ ̝@Ϗ➪Q4'1Lڷɧ<<}[(@vru肟̞@̽幹=줢Z<@">xWO~BE  /PwgP蛖gfO[綛YYnyf@>"䷯L .1 ]><0{EfoYk_+ /;[:uyá@i~V0{@~sݬzdU(Y P?\eICZ>ph"PB"KZZnGBEG9π0)ECΗE-*/+yT!5Ͽ@@B#*~ORQ7I4=94i cMD" P?|YܳBT}Ѝo=}K@(@(,ڟq"8*2Dv>l=ݣ]Ktڧx*k³@ P?~YN=Pn:Dkz1]g TV̒P1ngT \y6YVn.gS@<"c+ ncRy)nLt|l[g9(*3bp˧r4 P@sz2 hK2 rPmVs9?`rg9U;Oe>"_,W_b:,yܲ[u \/=p%ae (ߗ|튞d+:^E*r5JA*RI ^7Mrb:_,WGn?-7WK \Ikk,}>kuf\;'&`-?X v}{m/G(>Pt8ii'U/,op_,D~Xk./;^4pDks|s0 X""P[RXr@%EX -xYӮ^L_~n~;n\yz4W0 \9 Chen0>w>l)khV[W_>Bg﮿*˕P.=— )\GUEuAi*ĝئ BmHr@%K>]XN o*ҳ&ZϣzuZ~ih}|ؿ7s&(b( |+M)ɰo;<&qsF쾪,Erɟ:i2"@qwLނc:wxLl[ ܴLOIW9dՉp"ͤ<7z SDBu΄g[5*ruG[fz)T)8x> ;n%&=NT { _uÓTw(:cmf(FkYSx᱀r&<_ w(r-;Vi!{sU0H9ܱw%C2Q!{*E\p"/m\ͩ˩mu*R)y(=p/Xx[ǡQzp"cY_d\*Xx[Gvx+пgp0YExXNU\V'޶ݬ?Gbm` x"<,mY~ЃNE10 9`'/32lY5M! fx? PGacK)^UzM! ? Pm׵ړcHKͽЯϠgx@SN%drU7 D؏*y4*~Zy>ų/Rʃᅥ)< i(BrEN(r+qWAQx]ГO(~Aij5˼j$'@eE RӒK~#Pv.3i5|ړaZr~(@;9-pOU1M, 'G -(vސ>G(}hwNn@4}k'- =*hA-l7%:cXXkJ_&^TNlЛ_\dz"E׹Vfb:sZBorDhIeD_ߔ}ZqZ]鵓O_Gg_@K?X(h-}|\SšZupIo~wl\ `sq?@KEh).`E~ړu)%Pܛh+?3ehO3J`x:FM$Py85?XC T'¨ HKTڼbՕb3@ <+s@(@-tRl/{8PG3 @ʰb"Ђ,0E(`Y Ğ,gs}/BE!|H2 V9U.>#;@!E(,w|\徇@=Ho(Dl7M\eZj{ޟsRS*@E(+nUP0 E(+wYD%b:P((# (@A:}ixŧsl{NbJXiuJEx&>Xx6/i{ i$|iڟaT'P@ +Z7ru o*hw.L"P:>f$۞cʿjmnc@r?sbE#"xJK9d9T|*,{8.̕vg "ԑ%bz6&Knm=Syo`sS5-E@Dj7.Wb[=ZReDžnwP@ɭ>5=c>U'@%߬-TX~ ݬ?/%fǻ(V?n:t@n_ ZC r'VQ6^N|XƬEhfkp6=sq*(@wr 5PlumsT*6J1X>c/1ڹ8X#Nݽ!Էʇ(+8ᰪl"ٶ٠ۏGܕ³ڰ},\둶>>>3Կڴ<bx5Sܛ^vaʆ IDATتF5$iD@:ݬϛ<,Yu]=֐ZՉOFv5c}]ų@wmϕ4{?ړSR)yF'ဇ8%\1"t/q(YjU0j ' BU'x9υ@n_ T !PVw5\!k(P1Ue {x(@?0Fb >sdz<>{Ёa,0^EA [n5*:&aX۝o =}]g@Ep {=Rړ&u Nʭ&@OП,##1qN)̀CX`ГBYn{._2T*W2z$P~=P5̧N.Vˤ _I _3H=*4帧+UTz"L8tC"/3n Lb 5QZn&GY"sm=(@J|9Jfi xH0e%UgEY yG;m7ڵdġ΁|,,QG0@!Jq]l}c#P98*P@{]eImϵóYctzj2R8}F]ٟAqy&OzbDDPx6NU}F`8 IiݬSӇʇI-g]k1J! }6|` "D|\t|E] OyCO=d:^5M?#ݢ CNLϤ/s%̾<Y*է܄ ;OvnXaٳ:RP*J*|P-ĩJqP+U'T Էuzu/4ͻT0AϢ_6|0ESچ*^F vNA?:c>'CŴGqenU|HubLf *-o `r{"Lu}]NfZ:M~[®?TZ_(p;z/ Hf}SKM>d  o S U&o9 &T݄6DşwI}ޙKΉ{i\=yK}P{pS= _~7o TT|rBGHrQ Xxˇ*ծruXF}kwO>?ܜs:q*؛wc~fiy/ԹUGDU |đK*4i^d_O"bJUg?Z=01N<& `N a{)61|iW]p. pb:Z,Wr"ְ/?=#CwC  z `bV-}*?+p S+?P沃HՈO:\ôS5dZP1Y:C@}ECUzRlvo,aP15o~TX2B=Fx8R5ḑ40f@X`ub`^،#TO{% 5F@9ڠnMb`|`FLy<ާfLu|׹=f7bS^~v=]GM e MvN&PqP#1*ŦJ9{62~&pĹJV~`f0.KFTL-V1|1HۿGމ0OET)6€,L}8f`0>r"uxa⍋ Q3$P)X8/BEvA0}FzNy(8_J*`iiLxv֮:FH#TJҗy"XN⽛m'?DgD)"W*ŃP6:t `<3T' `Xig&&:fNV!U)6BE ᅡ:FL#VJqp_==vD JijBu"@/יWd\ m%z STjG+NruAx2#i Pnֿab!z _ g.Ax6y3 1"Li*Z*Q(pF8k=gDB$3"L@*h+CClr@혼Jp<JAu"L@&bYaWW7=#Т?sN1'L@; =CcrF{OV5dze&`Bu"rY忧PPWs!TŖ/L@^gχo`Okݛ39e:7̆@&fY_4MUŷPєͶռ`Ľ)I`JTP9Wu4E`B!ۛr?!Tt0gM#~g01ETat]F1LPLX`0QB{1Rǡ*E&'>%3 "Lv>i~@ˍCE(2)\ų("L_J'cj_(T|QkYϥz&Nݬ/T*ӀLۍPccTg O&LPbD;du_VB !Pn֩]~RhﵮUh}xYyI ۷LfD„Wz\jqfx6j-}]८|`0C4cJM[sڧfwVgX`0S`-OըZ#1Dbd-QY;tj;gi0CER [V㾝U%/um ̛@f,J4klUu4>''ę۲֧ѵ>؏)тΗڳ4䌱>V.=A 1Uʿҭ5O`tbϋ!ɕInG#O]Egd/"b#iܵ2yBʻaYj T#P$KDWx4g.ك̽.Z ol7T} yʴa*aOŷĒY'E>).:O\ͷc0xZTȔBt-cK.8 "pS_,ڝ- Ԏ}Pcˍ(rZ{Ecϧjh9 Z/?+x*?m7g5>.U9k3 "=> t2ck-iߚÉuy|r |@xP秋jan_u\GU~]/zZ:9g`wEc7`:qRq m?i8JIZiʏ*2]V|z9@+?X&TuP<6Jʭi1 G9[,W?^xjND+s/Vg-"J ab/Vf?!T*Ts:/p"|c\׮*ԾVg1<ŔڷV@S|9<h\^m Gn''a?𾉟3 К@Q (<\Qa Rx(-c=T)laJ8Ľ!(;n)PhO@P7C|MHJ `)woSM2h!PvݬM|W0;{=`D$>%  "%& ThO RTrğL-r liVb:]9*,UIY"PJ9*rU{ km M|^:+SR@S<],Wj;ܴ^Ge F% @1E)nϛ0ўr FMKUx?'D<'Pj(rU29,τ M }*@qS|]pHˁ=_<5&U* 律/4EĽyR "P>|qgD&鋂aYyZ@mDZga 5'?C*Lt@5E[)^:ӦiLe*N.ZK?"P] @)9meй_+<9;gG45=vV8L (Sl?w"ߨ&^= 0:E`Mbx0*R0nE`"9lugRx-L@vBE &P&aY*rL@ʡ;e=&|@Kt{ I(s+T,M8AFL@r^U6T _ (ݬτܧr&KLZPb\N"0yCMG$ޫxJ& PfbT8ħNX̆@BgaFP@(S1T*˭0q‰ Y(A?.|)e\/tS̕@f}4AP1y/TO 'wfIv\9TTֱXaA/@eE`*/݉~YD P&TX~uMk,LOnW uܚ&P%P]VXbat<&@+רT*EhtX_bMK_Ǻ>A&@X՘|&kpUf\7Ms,j'ۜVz?Z(T(|GL*h6;b.(AO* bXbmT$LhGvN*a-54|%y--aY4uu3+{xOhIH<&@r>}ӵ5HkQ1L@`s4e{-гW1"֠=G(hYJZŵ^Tr_*> 2l7_uPiށZ,WW>*ʕ^74ŵX.b엽Oi_Ÿ/qm5+"@AiWi_߷_*8Lr>$P( ϋ|-|aLrDP +@ǹ~sI* ЇV󓊇IWMrGP٭a-UlQ+(t 諊Gi>{R:rkX˧GL^,WW9r'W%PP쫘U>ruX~1U T>ԻK@}G QWWJaӊ/qhHГ[*^V4b:,_*^ibЯoX,W$ߘgs.|~wiYvpC0 *U+WnNb] 5'87_v|Z( LuxCUS8 @`IFKؽn'M( X-C`Ly;=æB`$:SFB0"Y4gM"̘@`P*`CD(L\ՊcD (b:`tu7cy/U+~(xk C" -i>Owhop̋@`Ur6|ݬO7$Pڒ—Y1(Akob:&*Ϭ7@kT@[EoHa2@kZc ,c0 @ȂA pg8h(ݳ==TUvUuE!鮮_ޙL$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$([- IDAT@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@;TZ^Vw_<2?M)$ FkDpX^`1~n"dLϐ~juxpỉ@NO :;8>խV V;8j:;8>;8.BV7.XuOro{Ǵ\ܧxasW+xIg?1{5XڤS4 v:B|2F(fxׁSQlEAjH^U#>8hח쫺qD@ӉT_o5XO.6$*^xo|x31Y3 "E0K}~z)"Yc03u?oTŭe>w|ܨZ :]d+*hsExwp{7ܣtϟ).lCX00q]_Ҩ6sA`%\&8]|&݁to"[n_PH*kZc)Wm-q,.r#nߘJxwQ8P"c_/"_3$;Jevp{6̻:wPqdZse5Q^%{L)tYݳî7iRvK;taN{zeU hjA뢫Y{`ӦG${WL<~M|Qִg:%PW-GzyEcƚ2i?F5V}:#8Zn8}2S$;e2N]ؤt&G1❱fVշUQU'Fzݢ>rg-B8WWz]`psS/h3\=?ڙS|'W͟m];,3e }&~tVw^L~4噾>+踿ƨ=|"-3ƺYbXu<n謏J|-ܦ >s{p,A3x4xN6]1,* 2Aϸ&|UAeQXc3,6E3jMq୪^c'c /kqC}f"Gwe/ɆYonډ9QA6:):JP~;6?x6tmŹssy6`!4_=VvFtMe)> oFu!.{^X:yYu)[c\gvhі>i3uTOMySEжZj0Q2:m>QnbGėciT6V\yGMG`NiUw>*Ū>iɆs eM1`tqUlBq)k6,앱) }Sߛ'&8WS>78?u}q?:-MruC Ĵ蓨Xl:-01mLMJ.TQS5mYwbI9U(w4hSF3|+'ٴnۀ(Òotd&;P0:6(˜8қNџRYܷɻդβg_ѱ2y.ɮ׶`1Fw\W7"=LwbG}kuBx5N>wv>3iJgs]T2~l^=/;0'S(](B6vplR6F#ZQ8ii xjYY0,̽ߜqJԹS j^ jtpB.+Gt&VڛZ[u3ջ~r@tvqYLdžp$ /jZoKBӎҫ ns\9_FR]7 ^Ch ӞLmڙC8(B Oq}D@C ]?xoޛ: PEivĻ_ؔ6UCOf9?Lw~iALB]hf,b`E (B8gCuR5;Z6ξiUP|ΝLw;97#\ihup}Ӷ~ gL]ㆬf۵Eg?-bk1m*T)2kEhKiS_ ^dW|7ehCQ{{};a]EgYXLw2:ek*{qEϜ:`T3*^Ro ䷽c*Puxdh0cq Q40=깂tngv{(m'A_fVGR:D-%B9ŵBŔCL}DaSEPxQD/;w8cqPkbdŋiw]fw&P?yRL=WUuiiM}lVb_qwpEh{,^DxwADi]؏黽{,ґu>mC3 d}sT*>™tq|\Y2"bؼ埫ȦCo;7l>R\2;@I氈xЬx ; \Mwm&-¥̊۳x>]T_c60] 0B<tgjӞKC>*bcõN;Lwifݾ}Uǹ1j4Sc{^κ\EcS]O>6I xMm)F;8nrNJO ~? -Dh6ֵ*>u;]GѮnsbMaB1]wR`bb-"QXc;8~+ѝEC3b쪯Ap  "qt=L4P,-Nh<lڇؤeΣ7pמvT\yDa`,VyB4Dž{7ʔ1N{EXT7Q yz-B CMyRZF.&xMH*||z:{u??kf+c[:gS.+wbm*0?#uaNؘ܏o:N]ͻ}mMMRT'c[BŮv{f)l$ax/BӬ~.FsUW0F1yxh08Dxp[T-:$(;GV6Mu3{Q1vp:'PͭOXj۔63wtA!O5ҳ4 DL LMOmޗ'P5 >7w/2e8iUӝ{?~Qmz12y$xnb=?Un3mJTMeUa! axM+N>T(3 eC9 Lwblym?$zz]#6cXeIF#ry5a4boJQ(ZtE;=Opvô&saZ쑝Mǯ`Cٚcyfۜ`0uo*08ʽĄ5 G(dsܷLgu6ybJ|0i6.XPʆ{BquEk<7np0[~ g׮ǑOOZ 99:eSsӝG,3lmo:4ݓeB2=I"09nZ&P]1Ow^rsտNxc=6xz-,N8!yIT+r7U˓im aXMžG_vUx:6$8Pa~($V>CTjwC.@YU Hj<5=:;>TBާ=ǿ+54MwXO,CTlΡJmbnoZ* R,Ò#0 TSR@!@ YzPlF, P}PES{2M?c*Ys;8V >1}6~\M+_ۜ`8EN]Tt:K5PL`c_?^4(}lLw^gxw:ӓ)T.fb@MɧW16UKoo Fi;*5Vӝ!*~a.M$*;@1*.@ EYT-]gGF׶e|SӘʪyyj39u ӝg2À~lҢS=-Sݟq([M6g@tZF1q6T5aPt]Ck0=M{jh潥{taL{\@ 5(`=6GQ9Ҵ3t'MF.7cp~xoMás(W%,L9˰IKqmMr|*oAY\/lZ}C?_M7cia-*]˩mΦ=9SB&STu1U9`~讧RZ-i=ȶ\ mz$PDciCHT !#8c穇fmƬ ʂ)~X\OZ'6ܦ>ز UUԩUv{@s٢:qZV)h.v.fPմΣȠfNӝg(Bru~dkŝ9;V'Ǯs}sMh6 .Vӝ$zGZpz?D;D/@de\m>*E_XF7DŽ.cq3o=mਪkq]>׬UMuwmmkhrtgLĽ6G͛6kEޗaqH,kZ, CQypb:Fu]ӆ޻ucGj3].w%^Yr2b|Mr Lw^8~/Ǽ1V;0u~FfP"7%q@=ßlE'ЭO#NZ%s+4M{sl7)fMs"ӝ&p>#g&氭Pr3)״繬MǾ"ӝ+^°>КMTۜ&ʰ¡H'ϳٳL.:'4:Dz90ݎϷ?l2=M;\<ZWاk7'T_@l X2l:RtA/ ו3'-*gE87c/n)kMSlZMt p[t۸hN!ZM ſC-=??=.)hۜn3 @!̭໨nΓ 2Les]|Kfv;ohOMw.5 m1J`eQ.MhE[s-"ˀnӾ\բ %"(2]ZL1|9 xmBŢ8im{Zm'ݔ+2ij&ޟ7v?iyNq\Nv% ڬI/LuM꘍K_]?$LmY XJr=sy?78z"K;Aљ\jmc]\a*rnbq\C1Fh#eR*Nw_^vVSWۖ.5ȎMR5~ALg x6OWǨиya#?GijQa8~zzf=4]*TnO0?j5%hB7ui ?"NsUC^T!\vT ڗW}Tb ڊγx9;ǸVQ|$ g=/RuxO{9__vgu>1u!H8f cA[B0p1 Y@Nl2:SR| 9ă"SV_=}}WN*R[:eqm`e 3>`ϷԜ^t!Ut/#ܘubR#uKĴComR;'껸}}f' mN6S_ χy9z.Ne}< {<~p#P{K8D,oz=nZlԦKkaB̹q/ ίQ..\؇X[`dWtAğcsQ\H9o}< :~S!PK6et7x,e]Et>#֗fkEꜯS3UT΢so{Qr3 u @>;tI~/ɇ@cѱVƮmw}]=:zy눥n*RoT1wp*51dc-溏`>,2Y5mcO1ݘcwfzPR̕@ES~ylm3d׍`q@ϡR dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @H&P dE @Hw.엧sʽ㗫g/-^x͗]O_{=gzZ^l_Qw?{_v~8FU&S\q>wǿ8v}]kU{-Gu|NC3 ^\<⚋Ͻ^KQ'evͥQMUquc_:;֮j~wQVMﯷ~@hV<lGz:߻tyM>@V LrZz\YOjnǞ]}W)VOq2E|Z]|Z~;8+U8Q?s*5<66cqNuzrr}h>οˎ:c?O$:q_hFu? xvZr-ܚ~o*/Cx.\$eP*y-uZ޺Xp? 3;8\](_*Ľ㋨Te0q[9?S^Uls;y^qI F(c㛞* G)'K>~(3/+6iE8`/ګh\sahn.#8~a1ΙW #P+{H hHu FW+ѡMB}'ùEGEiWqt3gt?WbCŨrTWjVs?͛.1KmųHaR+ڜ|"PFtY5+#Lup гx_3ۊuNޗ~dk .]}юSlsgoUUtg}7 US}Kp{ӎӪJ1:At(¼=<`jE@&WP4n2U,|:_W}HaSw&uqM*+Cn+Um1l6A2 \e 7}**Ūq/Nؔ歮x&TdF]W.uz_cvΪgm$`w]N O"TO^L~ tj(Yt&W3JUB=P} (7:X9ۀ;wfvk4{}vTA"$~ReD&P|?-K6cV,}:󑫫w,۹ndž>Yɽn袲ٱ&ղʓ95w̛̋%]*9?tgm͎oҟ︲⮶ʓE3Չ1"WᲵlb6%P<^xҡitua}IO߂hb{"Aݔ\GgΠ,R*JQIq!ɷ]?gV)[@qܐ`sv]kӭ_9d[XeZ۰yT"7qMkUՉUa7Ob3j׏czUe;Nd 3T˶6gaĪҺAUZY::]TPl@-m\<(0ƼNUMcT?W[7Tf-ʪۉ%^.~,Q0)\׹Uz7gٌ)A'*XoMw*VrXUq)' KC^ѩF=Wn[;P3Gc&*Ѻb+L;Kz=d4u݅xV~xULU:dw9!' ۉXvM&lDBT)00`FuP{M4(>zS`~p0sG#P=e9 ߚju\2+Ut|*G['UuՉrEXʦyƂ05WWT5v];Yl޽G!aÐ.«Pq,2!&֮xv *TD=f3BUݷso6MmfMbMu⣵@):J\"S3HkUU'6Z.U* {SNw: ܹ?U|0kKlw#Vu6 dG5&UalpVVU'^j'"Hf,fY',QYGӁ&*D*|h0~NqβY*^LCujsh{[f,]lUydï5j@}t)[7*ŸJR(x\WDuHuaxU_0mc'8T:>bMݵ\L17 )Ѓ]M?v < "خkGv>]RPȘa^ۍF%UTHs {Չp{Y.Wv:*2YjU_ڙuݗ?%~YQH],X.U)vo4wGeV2Dqɲ즚XvWxVŽǽ`F~]x.0|~T.ٌcUReG>#ī7}ų2ڑwTbIK9kbl34d'Poe*SQ0N}CH_!Ѡ+iT FF0xUt?$u4]dW9wJ&M=4O;-4ksA*s]UG+]x8X󐃭$1h5Ѝ0=徺EbBح;?_W)T'ZfA 3PKYît&Jow|[EX笏hD8wZ3UM t:q者2wpՆلjݜf31T>UKb*L̲FUƲ~3 BPJYDHTܶ,z}qfU? -=' o; rjВ6`]8az%vIY足\*:@ t 簢pjx$Py(kO%Hӗ_Ɣ]E_19WW{)"zzmsmUoSx]ufs@Ѵ;zѠZqXCR6 0q5 5B~:njUNv/v!Itv1%lZ{~r׼YVǠr=mf3ՉĽ IFjs yX8u\6v{ub*vsm SSL˲V4PfctWN_tR ;^UUkv.+ۡ?5Кɜ'љ^{wQ}^Cu}3{|b^v?9cMZNGF}z9[ }:جGǝ10Jd\OEǷt UN1_gТfӅKUZKAZ '=))CG">tpf,cYퟪsf ;d$^ [/wFAV5]pcHW0I5.chpY#z@]x*j+ΏXNq]W>]^׃3ڜ,PDr ?IDAT_ퟚuT;(G˄5ǺQuy:(DlƒˑYhׅVVu/@TKGUc.e9hϸî!V)ڌ%hܕ~PؼSݏ%{쫖İ\!Pk\" #VV5ިR\ SIe{x9R5yjV:DXUc &z\]JTKn*^TQ%! wjǨqմN;Wq<~W=<릃us#}UR\km ǣߏbAɲ{tmƒ !W_٧>]^!X("LSf,ٜD&Ô*vnx5Fb [W.kBbcWKl+2{F~ٸz*ɲ`j5`*y}]Z,y=0q@׮% aK;S b^n±I.0qkn"9Iؑ1UkE9ݳenU[ګ՘S\[]vIo^C=zxcs>kV]Ta015vן+ѧFfGC,a;D U,Bcgt><V5!sn5aQ?olϭw;3*:M=UnӡcάSq\d`zH>B>G}AdFS2(T56RN4FNY4ƷÁm:pAėUſ+֫E!Loբvi1ċ:/氆V /{Ϯ˚{Ϙ;UwV$) iw}zKK3-5JWn} @vSYdUuZW%yD[ВV1}dkV2t-5ҫhy>^n)ab5u=@q]ދxŞnhG=/kvG5$ 6m^7[˿6S#\(´TU!j]W4όJӇJڏ]CKw)G (~jzv o6}0LCl|mdV;wSqj[\)hm='2]":k|q*խ}_C Sys')aEPy`٬Q}i1lЛh<\.w*-SL\ӊ+Žح $֕\7+¾TXstU@˙ŽjM柚lυ폻a:N\9 p{AHi;C0~0תcCojKlG1)K9­;pty(ȍo_ ?"L@f,F^o2C>*E4su:bMFӛbY?d |~0;*_dY*8sTA1X4I1sk5]S(7T_b} τY0X(4TmJa,ZI.A}aHT+^Df*S3&(˜ϖ*°)Οf*|Y?{ԃ8 jcP*܆{tw9ԭf_@d zlNi͘*6 bsrˍkfǿXu3cq^Ʈ۾ύK~Z_]î_@Hf3L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@2"L$(@jM2IENDB`w666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@6666_HmH nH sH tH 8`8 Normal_HmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List 8 @8 Footer  H$CJlR@l Body Text Indent 2$ 0*$^a$@CJOJQJTT@T  Block Text00]0^`0 @OJQJ6U`!6 5U0 Hyperlink >*B*phH2H ow0 Balloon TextCJOJQJ^JaJN/AN ow0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VGRU1a$N% ʣꂣKЛjVkUDRKQj/dR*SxMPsʧJ5$4vq^WCʽ D{>̳`3REB=꽻Ut Qy@֐\.X7<:+& 0h @>nƭBVqu ѡ{5kP?O&Cנ Aw0kPo۵(h[5($=CVs]mY2zw`nKDC]j%KXK 'P@$I=Y%C%gx'$!V(ekڤք'Qt!x7xbJ7 o߼W_y|nʒ;Fido/_1z/L?>o_;9:33`=—S,FĔ觑@)R8elmEv|!ո/,Ә%qh|'1:`ij.̳u'k CZ^WcK0'E8S߱sˮdΙ`K}A"NșM1I/AeހQתGF@A~eh-QR9C 5 ~d"9 0exp<^!͸~J7䒜t L䈝c\)Ic8E&]Sf~@Aw?'r3Ȱ&2@7k}̬naWJ}N1XGVh`L%Z`=`VKb*X=z%"sI<&n| .qc:?7/N<Z*`]u-]e|aѸ¾|mH{m3CԚ .ÕnAr)[;-ݑ$$`:Ʊ>NVl%kv:Ns _OuCX=mO4m's߸d|0n;pt2e}:zOrgI( 'B='8\L`"Ǚ 4F+8JI$rՑVLvVxNN";fVYx-,JfV<+k>hP!aLfh:HHX WQXt,:JU{,Z BpB)sֻڙӇiE4(=U\.O. +x"aMB[F7x"ytѫиK-zz>F>75eo5C9Z%c7ܼ%6M2ˊ 9B" N "1(IzZ~>Yr]H+9pd\4n(Kg\V$=]B,lוDA=eX)Ly5ot e㈮bW3gp : j$/g*QjZTa!e9#i5*j5ö fE`514g{7vnO(^ ,j~V9;kvv"adV݊oTAn7jah+y^@ARhW.GMuO "/e5[s󿬅`Z'WfPt~f}kA'0z|>ܙ|Uw{@՘tAm'`4T֠2j ۣhvWwA9 ZNU+Awvhv36V`^PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!g theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] 442c*m4"^4" 4X8@0(  B S  ?FJ6pt:=?K633333QU=P :c<xx  $ 6 _ : ; r s 88OOw}*>not~7>-88FRffrr36QU=P xxr s w}t~7>FR36pZzV[^`o(.pZoSh U5|oSh   |j/ R5U4EY^[cowe,s+46__Grammarly_42____i__Grammarly_42___14H4sIAAAAAAAEAKtWckksSQxILCpxzi/NK1GyMqwFAAEhoTITAAAAPH4sIAAAAAAAEAKtWcslP9kxRslIyNDY0N7awtLAwNjUEIksTEyUdpeDU4uLM/DyQApNaAAKKMhcsAAAA@4@UnknownG.[x Times New Roman5Symbol3. .[x Arial9.. Segoe UIC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"qhfgK /K /q20''KQHP  $P5U2!xxRX  najmanrDawn Skeete-Walker Oh+'0  < H T `lt| najmanr Normal.dotmDawn Skeete-Walker2Microsoft Office Word@^в@RA)@Ga@GaK ՜.+,D՜.+,d  px   SUNY Downstate Medical Center Document/ '  Title8<p| _PID_HLINKSContentTypeId$_ip_UnifiedCompliancePolicyUIAction&_ip_UnifiedCompliancePolicyPropertiesAl_http://www.downstate.edu/,0x010100815B80A603542D4F87FD0740BEA1D46F  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`acdefghijklmnopqrsuvwxyz{}~Root Entry Fe8iData 1Tableb#WordDocument 42SummaryInformation(tDocumentSummaryInformation8|MsoDataStoree8ie8iQ4TPCENKJ==2 e8ie8iItem  a8PropertiesZFNOWG35ZQW0IQ==2 e8ie8iItem  PropertiesOCompObjr This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision.   DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q