Oregon_Temp_License.pdf

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INSTRUCTIONS FOR THE APPLICATION FOR TEMPORARY RESTRICTED EMS PROVIDER LICENSE

Oregon Administrative Rule 333-265-0056

Purpose:

To authorize an out-of-state EMS provider to treat individuals involved in responding to a wildland fire in Oregon.

Qualifications:

• The individual must be licensed and in good standing as an EMS provider in another state.

• The individual must hold a current certification from the National Registry of EMTs (NREMT).

Procedure:

1. The agency manager, medical unit leader or designated representative will contact the Oregon EMS office with the request for temporary licensure.

Contact information:

Leslie Huntington 503-931-0659 Leslie.D.Huntington@state.or.us

Or Oregon EMS and Trauma Systems’ main phone number:

971-673-0520

2. The Application for Temporary Restricted EMS Licensure will be provided to the agency representative.

NOTE: a separate background check may be required.

3. The agency representative will return the completed applications as well as the name of the supervising physician providing oversight during the wildland medical operations to the Oregon EMS office.

Email address: Leslie.D.Huntington@state.or.us

Mailing address:

Leslie Huntington, Oregon EMS Rogue Family Center, DHS/OHA

3131 Avenue C White City OR 97503

PUBLIC HEALTH DIVISION

EMS and Trauma Systems

Kate Brown, Governor

800 NE Oregon Street, Suite 465 Portland, OR, 97232-2162

Office: 971-673-0520 Fax: 971-673-0555 www.healthoregon.org/ems mailto:Leslie.D.Huntington@state.or.us mailto:Leslie.D.Huntington@state.or.us

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4. The Oregon EMS and Trauma Systems office will notify the agency representative when each license is approved. A temporary restricted license for each individual will be generated and emailed to the agency representative and/or medical unit leader.

For questions or clarifications on the process, contact Leslie Huntington at 503-931-0659.

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APPLICATION FOR A TEMPORARY RESTRICTED EMS PROVIDER LICENSE

Reference: Oregon Administrative Rule 333-265-0056

Level of Licensure (circle one): EMR EMT AEMT Paramedic

Name of Fire Incident (If Applicable): __________________________________________________________

Name of the Medical Unit Leader (If Applicable): __________________________________________________

Email Address of Medical Unit Leader Phone Number of Medical Unit Leader

Name of Contracting Agency Name of Supervisor/Chief

Email Address of Agency Representative Phone Number of Agency Representative

Applicant Information

Last Name First Name M.I. Social Security Number

Mailing Address City/State Zip Code

Date of Birth Email Address Cell Phone Number

Driver’s License Number or Gov’t ID State Expiration Date

National Registry Certification # EMS Provider Level Expiration Date

State EMS License Number Issuing State Expiration Date

Portland, OR, 97232-2162

Office: 971-673-0520

Internal Use Only Date Rec’d ________

NREMT Verified _______ State Lic. Verified ____

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APPLICATION FOR A TEMPORARY EMS PROVIDER LICENSE, CONTINUED

Personal History Questions

IMPORTANT: Check “YES” or “NO” to the each of the questions below. If you answer “YES” to any of the following questions, you MUST attach a complete explanation and supporting documents to this application in a sealed envelope marked “CONFIDENTIAL.” If you fail to attach appropriate explanatory material or additional information is required, you will receive a request for additional information. Failure to provide full and complete explanatory material WILL result in a delay of licensure. Answering “YES” will NOT necessarily result in denial of your application for licensure.

Question YES NO

1. Do you have or have you had within the past 10 years, any physical or mental condition that impairs, could impair or has impaired your ability to perform the duties of an EMS provider?

If you answer yes, explain whether your condition is controlled by medication or other treatment and how your condition treated or untreated, affects your ability to perform the duties of an EMS provider.

2. Do you or have you used in the last 10 years, any drug or chemical substance for other than legitimate medical purposes that impairs or has impaired your ability to perform the duties of an EMS provider?

3. Have you been counseled about, been diagnosed with, or treated for, a dependency on alcohol or drugs within the last 10 years?

4. Have you ever been arrested, charged with, or convicted of any misdemeanor or felony?

Minor traffic violations need not be reported.

5. Has an employer or supervising physician taken disciplinary action against you related to your duties as an EMS provider? Discipline includes suspension, letter of reprimand, resignation in lieu of termination, a limitation or restriction of scope of practice or dismissal for cause.

6. Have you been named in a lawsuit alleging medical malpractice or misconduct related to the provision of medical care?

7. Have you ever been disciplined, denied or revoked by the National Registry of EMTs or any health care certifying or licensing agency?

8. Have you ever surrendered or resigned a health care license or certificate?

APPLICANT ACKNOWLEDGEMENT AND SIGNATURE

I have read and understand the provisions of ORS Chapter 682 and Oregon Administrative Rules Chapter 333 governing licensure of emergency medical service providers. I understand that the making of false statements in connection with this application is a violation of ORS 162.085 and may constitute grounds for denial, suspension or revocation of an EMS provider license. I understand that a criminal history check may be completed on me per ORS Chapter 181.

Applicant Signature Date

Internal Use Only Background Check Required? _____

Date Completed_____ License Number________________

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TEMPORARY RESTRICTED EMS LICENSURE FOR WILDLAND FIRE RESPONSE

Name of License Holder: ____________________________________

EMS Level: ___ __ Oregon Temporary License #: T16-

Date of Issue: __________ Expiration Date: ______________________

This license is valid for 90 days from the date of issue and is only valid for the provision of emergent and non-emergent medical care to those individuals engaged in a wildland fire response in Oregon. The individual licensed must comply with Oregon Revised Statute (ORS) 682 and all rules adopted under ORS 682. The individual must practice with written standing orders issued by a supervising physician as described in OAR 847- 035-0030.

Portland, OR, 97232-2162

Office: 971-673-0520

Wildfire Medical Directors

Poulsen, Christoffer E, DO emdoc04@gmail.com 2770 Rivermark Loop Eugene, OR 97401

Stone, Sean, MD docstone1@yahoo.com 2745 NE 51st AVE Portland, OR 97213

Vets, Steven, DO svets@santiamhospital.org PO Box 1857 Corvalis, OR 97339

Clothier, Brian D, MD brianclothier@mac.com 2741 Harding Avenue NW Salem, OR 97301

Lehrfeld, David, MD David.p.lehrfeld@state.or.us 800 NE Oregon St.

Portland, OR 97232 mailto:svets@santiamhospital.org mailto:David.p.lehrfeld@state.or.us