A health care staff agency submits this form to notify OHCQ of a referral to a Health Occupation Board, such as the Maryland Board of Nursing. If an agency is aware of an action or inaction by a health care practitioner who is provided or referred by the agency that may be grounds for action under Health Occupations Article, Annotated Code of Maryland, the agency shall report the action or condition to the appropriate Health Occupations Board and OHCQ immediately when the action or condition is known by the agency.