Please write the name in full, without abbreviations.

I verify that the EMS agency is in compliance with Oregon EMS statutes and rules, including but not limited to:

• Agencies must carry all required pediatric patient care and pediatric safe transport equipment for their licensed vehicle type(s).
• Agencies must submit complete patient care reports that include data points in the NEMSIS data dictionary.
• Agencies must submit patient care reports that meet specifications of all NEMSQA pediatric measures and other NEMSQA measures under review by the Oregon EMSC Program.
• If applicable, upload all current waivers in the File Upload section at the end of this form.

For references, see the Peds Ready EMS Application Guide.

Initial below to verify.

Enter the name of the agency's Pediatric Emergency Care Coordinator or Pediatric Champion, designated during annual EMS agency license renewal.

I verify that all EMS providers on agency roster have completed required pediatric education for their provider license type.

For references, see the Peds Ready EMS Application Guide.

Initial below to verify.

Describe the agency's community outreach and education activities. For examples of relevant event types, see the Peds Ready EMS Application Guide.

Initial application: For agencies submitting an initial application to the Peds Ready EMS Program, describe at least one outreach activity completed in the previous year.

Renewal application: For agencies renewing their Peds Ready EMS recognition, describe outreach completed in the previous two years.

If available, upload supporting documentation in the File Upload section at the end of this form. Examples of documentation: event flyers, communications with staff or volunteers, photographs from the event, etc.

I verify that the agency has signed up for the Oregon Registries for EMS app and enrolled all providers on agency roster.

Initial below to verify.

I verify that the agency encourages all providers to access HERO Kids Registry information, by using the app or confidential provider hotline, when treating patients ages 0-26.

Initial below to verify.

I verify that the agency has knowledge of city, county, district, regional, and/or state disaster plans that include considerations for the unique needs of children.

Initial below to verify.

I verify that the agency has developed a SOG, SOP, and/or MOU that describes agency utilization of city, county, district, regional, and/or state disaster plan requirements. Participation in multi-agency development of plans (e.g., a county ambulance service plan) also qualifies.

Upload supporting documentation in the File Upload section at the end of this form.

Initial below to verify.

I verify that the agency participates in disaster exercises occurring within the agency's service area.

Initial below to verify.

I verify that the agency has completed and will continue to complete the Prehospital Pediatric Readiness Project assessment as requested by the Oregon EMSC Program.

Initial below to verify.

What has the agency identified as the primary areas for growth or improvement of its pediatric readiness? Provide at least two examples. How is the agency working to address these gaps?

Note: Refer to the Prehospital Pediatric Readiness Project assessment gap report.