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 t 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