Yes No

[   ] [   ] Letter received from EMS agency requesting the services of the physician as OMD.

[   ] [   ] If the EMS agency currently has an OMD, the letter must state name of the physician to be replaced and indicate that the current OMD is aware of the agency request.

[   ] [   ] Short resume or CV received from physician. Receipt of the resume is taken as agreement by the physician to service.

[   ] [   ] Physician is licensed to practice in Virginia.

[   ] [   ] Physician practices in the PEMS geographic area.

[   ] [   ] Extensive experience in emergency care such as cardiac arrest, respiratory distress, or multiple trauma.

[   ] [   ] Current practice involves emergency care such as cardiac arrest, respiratory distress, or multiple trauma.

[   ] [   ] Physician understands the responsibilities of the OMD as specified in the Virginia Rules and Regulations.

[   ] [   ] Physician understands the accompanying membership in the Regional Medical Advisors Committee and the attendance expectations.

[   ] [   ] Physician understands the regional nature of the Peninsulas EMS system and agrees to bring proposed changes in the patient care standards to the regional Practice Subcommittee prior to implementation.