— Seeking Information in Bradford Ferrick Investigation

CONTACT INFORMATION

First Name

Middle Name

Last Name

Date of Birth

Year / Month / Day

Phone Number

Email Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionnaire (continued)

1. I am filing this form out on behalf of:

Myself
My minor dependent(s)

2. If filling out this form for a minor dependent(s), please provide the minor dependent’s first name, last name, and date of birth

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3. Did you or a minor dependent(s) have contact with Bradford Ferrick?

Yes
No
Unsure

4. At which facility do you believe you came into contact with Bradford Ferrick?

Upstate University Hospital
Upstate Galisano Children Hospital
Baystate Medical Center Department of Family Medicine-Baystate Franklin Family Medicine
Baystate Medical Center Department of Pediatrics
Baystate Medical Center Department of Emergency Medicine- Pediatric Emergency Medicine
Other: please name the facility

If Other, please specify facility:

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Seeking Information in Bradford Ferrick Investigation

fbi

federal bureau of investigation

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