A form must be filled out by the individual who needs to report any changes to your
A licensed emergency medical services provider must notify the Oregon Health Authority, Emergency Medical Services and Trauma Systems Program (Authority), using the Authority's Reportable Action E-4 Form within:
Ten days of occurrence, if any of the following occurs:
- Conviction of a misdemeanor or felony;
- A felony arrest;
- A disciplinary restriction placed on a scope of practice of the license holder by the EMS Medical Director;
- A legal action being filed against the license holder alleging medical malpractice or misconduct;
- A physical disability that affects the ability of the license holder to perform all of the duties at the level licensed;
- A change in mental health which may affect a license holder's ability to perform the duties of an emergency medical services provider.
Thirty days of occurrence, if any of the following occurs:
- A change in legal name;
- A change in home address;
- A change in phone number;
- A change in EMS affiliation;
- A change in medical director. This notification is not necessary when the emergency medical services provider is affiliated with an EMS agency that is on file with the Authority.
The Authority may, at its discretion, initiate an investigation based upon being notified of any of the items specified in this rule.
Individual Quarterly Reports, required to be submitted to the Professional Standards Unit each quarter, can be found in your
Failure to Notify
Failure to notify the Authority of any items specified in this rule may lead to suspension or revocation of an emergency medical services provider license or the licensee being placed on probation.