PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on the use of antipsychotic medication in nursing homes are requested to complete this reply form as soon as possible, but no later than close of business Wednesday, February 11th, and mail, email or fax it to:

Michelle Newman
Legislative Analyst
Assembly Program and Counsel
Room 442 - Capitol
Albany, New York 12248
Email: newmanm@assembly.state.ny.us
Phone: (518) 455-4371
Fax: (518) 455-4693
box
I plan to attend the public hearing on "Use of antipsychotic medication in nursing homes" to be conducted by the Assembly Committee on Health on February 18th.
box
I have been invited to make a public statement at the hearing. My statement will be limited to 10 minutes, and I will answer any questions which may arise. I will provide 10 copies of my prepared statement.
box
I will address my remarks to the following subjects:


box
I do not plan to attend the above hearing.
box
I would like to be added to the Committee's mailing list for notices and reports.
box
I would like to be removed from the Committee's mailing list.
box
I will require assistance and/or handicapped accessibility information. Please specify the type of assistance required:


NAME:

TITLE:

ORGANIZATION:

ADDRESS:

E-MAIL:

TELEPHONE:

FAX TELEPHONE: