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Report of Change
All changes must be submitted using this form within thirty days of the effective date of that change (see CAMTS Policy 5.12.00)
Fees may be incurred with Class II and Class III changes (see CAMTS Policy 04.05.00) or may result in a supplemental visit.
A Class I change is a minor change that will have little effect on the overall mission, direction, and operation of the service.
A Class II change is a change that has the potential to cause other changes within the service as reflected in the mission, scope of care or policies, for example, that would alter the service significantly from the service reviewed during accreditation deliberations.
A Class III change is a change that interrupts the service or causes overall differences that would alter the service significantly from the service reviewed during accreditation deliberations and will probably require a supplemental visit or may require a new application at the Board’s discretion.
Date Time
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Program Name
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City and State of Program's Home Base
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Your Name
First
Last
Your Title
Your Email
Your Phone
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Check all that apply - Then check specific change at each Class.
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Class I
Class II
Class III
Other
If you have had an accident or incident, please go to www.camts.org - download/forms and fill out the the accident report.
Class I Changes
Change of address (email or mailing address)
Change in personnel occupying management positions (include who held that position previously and contact info for new person and their title)
Deleting a part of the service
Removing an aircraft/ambulance
Describe the Class I Change in Detail
Class II Changes
Adding an additional aircraft/ambulance
Adding a base in the same state or region (in the same mode of transport as previously reviewed)
Moving a base to another address
Changing ownership of the service but middle managers and aviation/ambulance operators are same.
Adding a specialty care team or changing the composition of the specialty team
Expanding into fixed wing or rotorwing but with the same FAA 135 operator
Merging with another CAMTS accredited service
Change in your HPS submission such as adding a scenario for a new scope of care or changing to a different simulation center or instructor
Describe Class II Change in Detail
Class III Changes
Changing the aviation operator or ambulance vendor
Change in ownership that includes change in managers, teams and or aircraft/ambulance operator
Merging with a non-CAMTS accredited service
Changing the mission statement and/or scope of care
Expanding into fixed wing or rotorwing with a different FAA 135 operator or with its own Part 135 certificate that did not exist at the time of the site visit
Adding a ground interfacility service
Changing the composition of the regularly scheduled team
A legal settlement against the service regarding a transport or patient care issue
Contracting with a new Communications Center or developing its own Communications Center
Adding a base in state or region not already located in (in the same mode of transport as previously reviewed)
Describe Class III Change in Detail
Change Not Specifically Listed Above
Please describe change in detail.
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