EMS & Trauma Systems Complaint Intake Form

EMS & Trauma Systems Complaint Intake Form

Thank you for expressing your concerns with the Oregon Health Authority (OHA) Emergency Medical Services and Trauma Systems Professional Standards Unit (PSU). The information provided will be carefully reviewed to determine if the complaint identifies a potential violation of applicable Oregon Revised Statute and/or Oregon Administrative Rules enforced by PSU. If it is determined that your concerns may fall under the jurisdiction of another agency or organization, OHA will notify you and provide you with that information.

OHA will keep complaint and complainant information confidential as required by law. Please note that there may be circumstances, such as during an investigation or a hearing, where your identity as the complainant may be disclosed.

To facilitate OHA’s review, please complete this form as thoroughly as possible. If you prefer not to disclose your identity, you may indicate n/a rather than provide your name or contact information. However, this may impair OHA’s ability to review or investigate your complaint.

If you need any assistance with filling out this form or if you have any questions, please call 971-673-0520 or email us at EMS.psu@odhsoha.oregon.gov.

Complainant Information

Date

Enter today's date

Complainant Name*

Enter complainant name or the name of the reporting party. If you wish to remain anonymous, enter N/A.

Relationship to Complainant*

What is your relationship to the complainant? If you wish to remain anonymous, enter N/A.

Complainant Phone number*

Enter complainant phone number or the phone number of the reporting party. If you wish to remain anonymous, enter N/A.

Complainant Email*

Enter complainant email address or the email address of the reporting party. If you wish to remain anonymous, enter N/A. Without contact information, we are unable to follow-up with you regarding the complaint.

Complainant Mailing Address*

Enter complainant mailing address or the mailing address of the reporting party. If you wish to remain anonymous, enter N/A. Without contact information, we are unable to follow-up with you regarding the complaint.

Complaint Information

The following information is being requested to determine if the complaint violates any applicable Oregon Revised Statute and/or Oregon Administrative Rules.

Date and time of Incident*

Enter the date and time of incident(s). If unknown, enter N/A.

Complaint Type

Select the entity in which this complaint is referring to.

Select

EMS Provider/Ambulance Service/Fire Department/Other Name:

Enter the name of the EMS Provider, Ambulance Service, Fire Department, or Other, if known.

Incident Address*

Enter the location of the incident. If unknown, enter N/A.

License Level/Level of Service

Example: Paramedic or ALS. If unknown, enter N/A.

Contact Information

Enter any known contact information for the EMS Provider, Ambulance Service, Fire Department, or Other. Include any emails or phone numbers. If unknown, enter N/A.

Witness Names and Contact Information

Enter any witnesses to the incident, if applicable.

Additional Reporting

Have you reported this incident or filed a complaint with any other agency or organization? Example: Adult Protective Services, Aging and People with Disabilities, or professional licensing boards? If so, please explain.

Complaint Narrative*

Describe what happened in detail. Include as much information as possible. If it is helpful (optional), use the "Who, What, When, Where, Why, and How" format. You may attach additional pages/documentation as needed.

File Upload

Drag and drop files here or

Summary*

To summarize, what does the complainant or reporting party believe the EMS Provider, Ambulance Service, Fire Department, or Other did wrong?

Send me a copy of my responses

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