Emergency Medical Services Providers And Supervising Physicians

Link to law: http://arcweb.sos.state.or.us/pages/rules/oars_800/oar_847/847_035.html
Published: 2015

The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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OREGON MEDICAL BOARD

 

DIVISION 35
EMERGENCY MEDICAL SERVICES PROVIDERS AND SUPERVISING PHYSICIANS

847-035-0001
Definitions
(1) “Advanced
Emergency Medical Technician (AEMT or Advanced EMT)” means a person who is
licensed by the Authority as an Advanced Emergency Medical Technician (AEMT).
(2) “Agent”
means a medical or osteopathic physician licensed under ORS Chapter 677, actively
registered and in good standing with the Board, a resident of or actively practicing
in the area in which the emergency service is located, designated by the supervising
physician to provide direction of the medical services of emergency medical services
providers as specified in these rules.
(3) “Authority”
means the Public Health Division, Emergency Medical Services and Trauma Systems
of the Oregon Health Authority.
(4) “Board”
means the Oregon Medical Board for the State of Oregon.
(5) “Committee”
means the EMS Advisory Committee to the Oregon Medical Board.
(6) “Emergency
Care” as defined in ORS 682.025(4) means the performance of acts or procedures
under emergency conditions in the observation, care and counsel of persons who are
ill or injured or who have disabilities; in the administration of care or medications
as prescribed by a licensed physician, insofar as any of these acts is based upon
knowledge and application of the principles of biological, physical and social science
as required by a completed course utilizing an approved curriculum in prehospital
emergency care. However, “emergency care” does not include acts of medical
diagnosis or prescription of therapeutic or corrective measures.
(7) “Emergency
Medical Responder” means a person who is licensed by the Authority as an Emergency
Medical Responder.
(8) “Emergency
Medical Technician (EMT)” means a person who is licensed by the Authority
as an EMT.
(9) “Emergency
Medical Technician-Intermediate (EMT-Intermediate)” means a person who is
licensed by the Authority as an EMT-Intermediate.
(10) “In
Good Standing” means a person who is currently licensed, who does not have
any restrictions placed on his/her license, and who is not on probation with the
licensing agency for any reason.
(11) "Nonemergency
care" as defined in ORS 682.025(8) means the performance of acts or procedures on
a patient who is not expected to die, become permanently disabled or suffer permanent
harm within the next 24 hours, including but not limited to observation, care and
counsel of a patient and the administration of medications prescribed by a physician
licensed under ORS Chapter 677, insofar as any of these acts are based upon knowledge
and application of the principles of biological, physical and social science and
are performed in accordance with scope of practice rules adopted by the Oregon Medical
Board in the course of providing prehospital care.
(12) “Paramedic”
means a person who is licensed by the Authority as a Paramedic.
(13) “Scope
of Practice” means the maximum level of emergency and nonemergency care that
an emergency medical services provider may provide as defined in OAR 847-035-0030.
(14) “Standing
Orders” means the written detailed procedures for medical or trauma emergencies
and nonemergency care to be performed by an emergency medical services provider
issued by the supervising physician commensurate with the scope of practice and
level of licensure of the emergency medical services provider.
(15) “Supervising
Physician” means a person licensed as a medical or osteopathic physician under
ORS Chapter 677, actively registered and in good standing with the Board, approved
by the Board, and who provides direction of, and is ultimately responsible for emergency
and nonemergency care rendered by emergency medical services providers as specified
in these rules. The supervising physician is also ultimately responsible for the
agent designated by the supervising physician to provide direction of the medical
services of the emergency medical services provider as specified in these rules.
Stat. Auth.: ORS
682.245

Stats. Implemented:
ORS 682.245

Hist.: ME
2-1983, f. & ef. 7-21-83; ME 7-1985, f. & ef. 8-5-85; ME 11-1986, f. &
ef. 7-31-86; ME 15-1988, f. & cert. ef. 10-20-88; ME 6-1991, f. & cert.
ef. 7-24-91; ME 1-1996, f. & cert. ef. 2-15-96; ME 3-1996, f. & cert. efg.
7-25-96; BME 6-1998, f. & cert. ef. 4-27-98; BME 13-1999, f. & cert. ef.
7-23-99; BME 10-2002, f. & cert. ef. 7-22-02; BME 18-2010, f. & cert. ef.
10-25-10; OMB 1-2011, f. & cert. ef. 2-11-11; OMB 13-2011, f. & cert. ef.
7-13-11; OMB 30-2012, f. & cert. ef. 10-22-12
847-035-0011
EMS Advisory
Committee
(1) There is created
an EMS Advisory Committee, consisting of six members appointed by the Oregon Medical
Board. The Board must appoint two physicians, three emergency medical services providers
from nominations provided from EMS agencies, organizations, and individuals, and
one public member.
(a) The two
physician members must be actively practicing physicians licensed under ORS Chapter
677 who are supervising physicians, medical directors, or practicing emergency medicine
physicians.
(b) The three
EMS members must be Oregon licensed emergency medical services providers for at
least two years and have been residents of this state for at least two years. At
least two of the three EMS members must be actively practicing prehospital care,
and at least one of the three EMS members must be a Paramedic.
(c) Two of
the six committee members must be from rural or frontier Oregon.
(d) The public
member or the spouse, domestic partner, child, parent or sibling of the public member
may not be employed as a health professional.
(2)(a) The
term of office of a member of the committee is three years, and members may be reappointed
to serve not more than two terms.
(b) Vacancies
in the committee must be filled by appointment by the Board for the balance of an
unexpired term, and each member must serve until a successor is appointed and qualified.
(3) The members
of the advisory committee are entitled to compensation and expenses as provided
for Board members in ORS 677.235.
Stat. Auth.: ORS
677.265

Stats. Implemented:
ORS 677.265 & 682.245

Hist.: BME
12-2001, f. & cert. ef. 10-30-01; BME 18-2009, f. & cert. ef. 10-23-09;
OMB 14-2012, f. & cert. ef. 4-17-12; OMB 30-2012, f. & cert. ef. 10-22-12;
OMB 10-2013, f. & cert. ef. 4-5-13
847-035-0012
Duties of
the Committee
(1) The EMS Advisory
Committee must:
(a) Review
requests for additions, amendments, or deletions to the scope of practice for emergency
medical services providers, and recommend to the Board changes to the scope of practice.
(b) Recommend
requirements and duties of supervising physicians of emergency medical services
providers; and
(c) Recommend
physician nominations for the State EMS Committee.
(2) All actions
of the EMS Advisory Committee are subject to review and approval by the Board.
Stat. Auth.: ORS
682.245

Stats. Implemented:
ORS 677.265 & 682.245

Hist.: BME
12-2001, f. & cert. ef. 10-30-01; OMB 30-2012, f. & cert. ef. 10-22-12
847-035-0020
Application
and Qualifications for a Supervising Physician and Agent
(1) The Board has
delegated to the Authority the following:
(a) Designing
the supervising physician and agent application;
(b) Approving
a supervising physician or agent; and
(c) Investigating
and disciplining any emergency medical services provider who violates their scope
of practice.
(2) The Authority
must provide copies of any supervising physician or agent applications and any emergency
medical services provider disciplinary action reports to the Board upon request.
(3) The Authority
must immediately notify the Board when questions arise regarding the qualifications
or responsibilities of the supervising physician or agent of the supervising physician.
(4) A supervising
physician and agent must meet the following qualifications:
(a) Be a
medical or osteopathic physician currently licensed under ORS Chapter 677, actively
registered and in good standing with the Board;
(b) Be in
current practice;
(c) Be a
resident of or actively practicing in the area in which the emergency service is
located;
(d) Possess
thorough knowledge of skills assigned by standing order to emergency medical services
providers; and
(e) Possess
thorough knowledge of laws and rules of the State of Oregon pertaining to emergency
medical services providers; and
(f) Have
completed or obtained one of the following no later than one calendar year after
beginning the position as a supervising physician:
(A) Thirty-six
months of experience as an EMS Medical Director;
(B) Completion
of the one-day National Association of EMS Physicians (NAEMSP®)
Medical Direction Overview Course, or an equivalent course as approved by the Authority;
(C) Completion
of the three-day National Association of EMS Physicians (NAEMSP®)
National EMS Medical Directors Course and Practicum®,
or an equivalent course as approved by the Authority;
(D) Completion
of an ACGME-approved Fellowship in EMS; or
(E) Subspecialty
board certification in EMS.
(5) A supervising
physician must meet ongoing education standards by completing or obtaining one of
the following every two calendar years:
(a) Attendance
at one Oregon Health Authority EMS supervising physician’s forum;
(b) Completion
of an average of four hours of EMS-related continuing medical education per year;
or
(c) Participation
in maintenance of certification in the subspecialty of EMS.
Stat. Auth.: ORS
682.245

Stats. Implemented:
ORS 682.245

Hist.: ME
13-1984, f. & ef. 8-2-84; ME 2-1985(Temp), f. & ef. 1-21-85; ME 5-1985,
f. & ef. 5-6-85; ME 7-1985, f. & ef. 8-5-85; ME 6-1991, f. & cert. ef.
7-24-91; ME 1-1996, f. & cert. ef. 2-15-96; OMB 6-2012, f. & cert.
ef. 2-10-12; OMB 30-2012, f. & cert. ef. 10-22-12
847-035-0025
Supervision
(1) A supervising
physician is responsible for the following:
(a) Issuing,
reviewing and maintaining standing orders within the scope of practice not to exceed
the licensure level of the emergency medical services provider when applicable;
(b) Explaining
the standing orders to the emergency medical services provider, making sure they
are understood and not exceeded;
(c) Ascertaining
that the emergency medical services provider is currently licensed and in good standing
with the Division;
(d) Providing
regular review of the emergency medical services provider’s practice by:
(A) Direct
observation of prehospital emergency care performance by riding with the emergency
medical service; and
(B) Indirect
observation using one or more of the following:
(i) Prehospital
emergency care report review;
(ii) Prehospital
communications tapes review;
(iii) Immediate
critiques following presentation of reports;
(iv) Demonstration
of technical skills; and
(v) Post-care
patient or receiving physician interviews using questionnaire or direct interview
techniques.
(e) Providing
or coordinating formal case reviews for emergency medical services providers by
thoroughly discussing a case (whether one in which the emergency medical services
provider has taken part or a textbook case) from the time the call was received
until the patient was delivered to the hospital. The review should include discussing
what the problem was, what actions were taken (right or wrong), what could have
been done that was not, and what improvements could have been made; and
(f) Providing
or coordinating continuing education. Although the supervising physician is not
required to teach all sessions, the supervising physician is responsible for assuring
that the sessions are taught by a qualified person.
(2) The supervising
physician may delegate responsibility to his/her agent to provide any or all of
the following:
(a) Explanation
of the standing orders to the emergency medical services provider, making sure they
are understood, and not exceeded;
(b) Assurance
that the emergency medical services provider is currently licensed and in good standing
with the Division;
(c) Regular
review of the emergency medical services provider’s practice by:
(A) Direct
observation of prehospital emergency care performance by riding with the emergency
medical service; and
(B) Indirect
observation using one or more of the following:
(i) Prehospital
emergency care report review;
(ii) Prehospital
communications tapes review;
(iii) Immediate
critiques following presentation of reports;
(iv) Demonstration
of technical skills; and
(v) Post-care
patient or receiving physician interviews using questionnaire or direct interview
techniques.
(d) Provide
or coordinate continuing education. Although the supervising physician or agent
is not required to teach all sessions, the supervising physician or agent is responsible
for assuring that the sessions are taught by a qualified person.
(3) Nothing
in this rule may limit the number of emergency medical services providers that may
be supervised by a supervising physician so long as the supervising physician can
meet with the emergency medical services providers under his/her direction for a
minimum of two hours each calendar year.
(4) An emergency
medical services provider may have more than one supervising physician as long as
the emergency medical services provider has notified all of the supervising physicians
involved, and the emergency medical services provider is functioning under one supervising
physician at a time.
(5) The supervising
physician must report in writing to the Authority’s Chief Investigator any
action or behavior on the part of the emergency medical services provider that could
be cause for disciplinary action under ORS 682.220 or 682.224.
Stat. Auth.: ORS
682.245

Stats. Implemented:
ORS 682.245

Hist.: ME
2-1983, f. & ef. 7-21-83; ME 13-1984, f. & ef. 8-2-84; ME 6-1991, f. &
cert. ef. 7-24-91; ME 1-1996, f. & cert. ef. 2-15-96; OMB 13-2011, f. &
cert. ef. 7-13-11; OMB 30-2012, f. & cert. ef. 10-22-12

Scope of Practice
847-035-0030
Scope of Practice
(1) The Oregon Medical Board has established
a scope of practice for emergency and nonemergency care for emergency medical services
providers. Emergency medical services providers may provide emergency and nonemergency
care in the course of providing prehospital care as an incident of the operation
of ambulance and as incidents of other public or private safety duties, but is not
limited to "emergency care" as defined in OAR 847-035-0001.
(2) The scope of practice for
emergency medical services providers is the maximum functions which may be assigned
to an emergency medical services provider by a Board-approved supervising physician.
The scope of practice is not a set of statewide standing orders, protocols, or curriculum.
(3) Supervising physicians may
not assign functions exceeding the scope of practice; however, they may limit the
functions within the scope at their discretion.
(4) Standing orders for an individual
emergency medical services provider may be requested by the Board or Authority and
must be furnished upon request.
(5) An emergency medical services
provider, including an Emergency Medical Responder, may not function without assigned
standing orders issued by a Board-approved supervising physician.
(6) An emergency medical services
provider, acting through standing orders, must respect the patient’s wishes
including life-sustaining treatments. Physician-supervised emergency medical services
providers must request and honor life-sustaining treatment orders executed by a
physician, nurse practitioner or physician assistant if available. A patient with
life-sustaining treatment orders always requires respect, comfort and hygienic care.
(7) Whenever possible, medications
should be prepared by the emergency medical services provider who will administer
the medication to the patient.
(8) An Emergency Medical Responder
may:
(a) Conduct primary and secondary
patient examinations;
(b) Take and record vital signs;
(c) Utilize noninvasive diagnostic
devices in accordance with manufacturer’s recommendation;
(d) Open and maintain an airway
by positioning the patient’s head;
(e) Provide external cardiopulmonary
resuscitation and obstructed airway care for infants, children, and adults;
(f) Provide care for musculoskeletal
injuries;
(g) Assist with prehospital
childbirth;
(h) Complete a clear and accurate
prehospital emergency care report form on all patient contacts and provide a copy
of that report to the senior emergency medical services provider with the transporting
ambulance;
(i) Administer medical oxygen;
(j) Maintain an open airway
through the use of:
(A) A nasopharyngeal airway
device;
(B) A noncuffed oropharyngeal
airway device;
(C) A pharyngeal suctioning
device;
(k) Operate a bag mask ventilation
device with reservoir;
(L) Provide care for suspected
medical emergencies, including administering liquid oral glucose for hypoglycemia;
(m) Prepare and administer aspirin
by mouth for suspected myocardial infarction (MI) in patients with no known history
of allergy to aspirin or recent gastrointestinal bleed;
(n) Prepare and administer epinephrine
by automatic injection device for anaphylaxis;
(o) Prepare and administer naloxone
via intranasal device or auto-injector for suspected opioid overdose; and
(p) Perform cardiac defibrillation
with an automatic or semi-automatic defibrillator, only when the Emergency Medical
Responder:
(A) Has successfully completed
an Authority-approved course of instruction in the use of the automatic or semi-automatic
defibrillator; and
(B) Complies with the periodic
requalification requirements for automatic or semi-automatic defibrillator as established
by the Authority; and
(q) Perform other emergency
tasks as requested if under the direct visual supervision of a physician and then
only under the order of that physician.
(9) An Emergency Medical Technician
(EMT) may:
(a) Perform all procedures that
an Emergency Medical Responder may perform;
(b) Ventilate with a non-invasive
positive pressure delivery device;
(c) Insert a cuffed pharyngeal
airway device in the practice of airway maintenance. A cuffed pharyngeal airway
device is:
(A) A single lumen airway device
designed for blind insertion into the esophagus providing airway protection where
the cuffed tube prevents gastric contents from entering the pharyngeal space; or
(B) A multi-lumen airway device
designed to function either as the single lumen device when placed in the esophagus,
or by insertion into the trachea where the distal cuff creates an endotracheal seal
around the ventilatory tube preventing aspiration of gastric contents.
(d) Perform tracheobronchial
tube suctioning on the endotracheal intubated patient;
(e) Provide care for suspected
shock;
(f) Provide care for suspected
medical emergencies, including:
(A) Obtain a capillary blood
specimen for blood glucose monitoring;
(B) Prepare and administer epinephrine
by subcutaneous injection, intramuscular injection, or automatic injection device
for anaphylaxis;
(C) Administer activated charcoal
for poisonings; and
(D) Prepare and administer albuterol
treatments for known asthmatic and chronic obstructive pulmonary disease (COPD)
patients suffering from suspected bronchospasm.
(g) Perform cardiac defibrillation
with an automatic or semi-automatic defibrillator;
(h) Transport stable patients
with saline locks, heparin locks, foley catheters, or in-dwelling vascular devices;
(i) Assist the on-scene Advanced
EMT, EMT-Intermediate, or Paramedic by:
(A) Assembling and priming IV
fluid administration sets; and
(B) Opening, assembling and
uncapping preloaded medication syringes and vials;
(j) Complete a clear and accurate
prehospital emergency care report form on all patient contacts;
(k) Assist a patient with administration
of sublingual nitroglycerine tablets or spray and with metered dose inhalers that
have been previously prescribed by that patient’s personal physician and that
are in the possession of the patient at the time the EMT is summoned to assist that
patient;
(L) In the event of a release
of organophosphate agents, the EMT who has completed Authority-approved training
may prepare and administer atropine sulfate and pralidoxime chloride by autoinjector,
using protocols approved by the Authority and adopted by the supervising physician;
and
(m) In the event of a declared
Mass Casualty Incident (MCI) as defined in the local Mass Casualty Incident plan,
monitor patients who have isotonic intravenous fluids flowing.
(10) An Advanced Emergency Medical
Technician (AEMT) may:
(a) Perform all procedures that
an EMT may perform;
(b) Initiate and maintain peripheral
intravenous (I.V.) lines;
(c) Initiate saline or similar
locks;
(d) Obtain peripheral venous
blood specimens;
(e) Initiate and maintain an
intraosseous infusion in the pediatric patient;
(f) Perform tracheobronchial
suctioning of an already intubated patient; and
(g) Prepare and administer the
following medications under specific written protocols authorized by the supervising
physician or direct orders from a licensed physician:
(A) Analgesics for acute pain:
nitrous oxide.
(B) Anaphylaxis: epinephrine;
(C) Antihypoglycemics:
(i) Hypertonic glucose;
(ii) Glucagon;
(D) Nebulized bronchodilators:
(i) Albuterol;
(ii) Ipratropium bromide;
(E) Vasodilators: nitroglycerine;
(F) Naloxone; and
(G) Physiologic isotonic crystalloid
solution.
(11) An EMT-Intermediate may:
(a) Perform all procedures that
an Advanced EMT may perform;
(b) Initiate and maintain an
intraosseous infusion;
(c) Prepare and administer the
following medications under specific written protocols authorized by the supervising
physician, or direct orders from a licensed physician:
(A) Vasoconstrictors:
(i) Epinephrine;
(ii) Vasopressin;
(B) Antiarrhythmics:
(i) Atropine sulfate;
(ii) Lidocaine;
(iii) Amiodarone;
(C) Analgesics for acute pain:
(i) Morphine;
(ii) Nalbuphine Hydrochloride;
(iii) Ketorolac tromethamine;
(iv) Fentanyl;
(D) Antihistamine: Diphenhydramine;
(E) Diuretic: Furosemide;
(F) Intraosseous infusion anesthetic:
Lidocaine;
(G) Anti-Emetic: Ondansetron;
(d) Prepare and administer immunizations
in the event of an outbreak or epidemic as declared by the Governor of the state
of Oregon, the State Public Health Officer or a county health officer, as part of
an emergency immunization program, under the agency’s supervising physician’s
standing order;
(e) Prepare and administer immunizations
for seasonal and pandemic influenza vaccinations according to the CDC Advisory Committee
on Immunization Practices (ACIP), and/or the Oregon State Public Health Officer’s
recommended immunization guidelines as directed by the agency’s supervising
physician’s standing order;
(f) Distribute medications at
the direction of the Oregon State Public Health Officer as a component of a mass
distribution effort;
(g) Prepare and administer routine
or emergency immunizations and tuberculosis skin testing, as part of an EMS Agency’s
occupational health program, to the EMT-Intermediate’s EMS agency personnel,
under the supervising physician’s standing order;
(h) Insert an orogastric tube;
(i) Maintain during transport
any intravenous medication infusions or other procedures which were initiated in
a medical facility, if clear and understandable written and verbal instructions
for such maintenance have been provided by the physician, nurse practitioner or
physician assistant at the sending medical facility;
(j) Perform electrocardiographic
rhythm interpretation; and
(k) Perform cardiac defibrillation
with a manual defibrillator.
(12) A Paramedic may:
(a) Perform all procedures that
an EMT-Intermediate may perform;
(b) Initiate the following airway
management techniques:
(A) Endotracheal intubation;
(B) Cricothyrotomy; and
(C) Transtracheal jet insufflation
which may be used when no other mechanism is available for establishing an airway;
(c) Initiate a nasogastric tube;
(d) Provide advanced life support
in the resuscitation of patients in cardiac arrest;
(e) Perform emergency cardioversion
in the compromised patient;
(f) Attempt external transcutaneous
pacing of bradycardia that is causing hemodynamic compromise;
(g) Perform electrocardiographic
interpretation;
(h) Initiate needle thoracostomy
for tension pneumothorax in a prehospital setting;
(i) Obtain peripheral arterial
blood specimens under specific written protocols authorized by the supervising physician;
(j) Access indwelling catheters
and implanted central IV ports for fluid and medication administration;
(k) Initiate and maintain urinary
catheters; and
(L) Prepare and initiate or
administer any medications or blood products under specific written protocols authorized
by the supervising physician, or direct orders from a licensed physician.
Stat. Auth.: ORS 682.245

Stats. Implemented: ORS 682.245

Hist.: ME 2-1983, f. &
ef. 7-21-83; ME 3-1984, f. & ef. 1-20-84; ME 12-1984, f. & ef. 8-2-84; ME
7-1985, f. & ef. 8-5-85; ME 12-1987, f. & ef. 4-28-87; ME 27-1987(Temp),
f. & ef. 11-5-87; ME 5-1988, f. & cert. ef. 1-29-88; ME 12-1988, f. &
cert. ef. 8-5-88; ME 15-1988, f. & cert. ef. 10-20-88; ME 2-1989, f. & cert.
ef. 1-25-89; ME 15-1989, f. & cert. ef. 9-5-89, & corrected 9-22-89; ME
6-1991, f. & cert. ef. 7-24-91; ME 10-1993, f. & cert. ef. 7-27-93; ME 3-1995,
f. & cert. ef. 2-1-95; ME 1-1996, f. & cert. ef. 2-15-96; ME 3-1996, f.
& cert. ef. 7-25-96; BME 6-1998, f. & cert. ef. 4-27-98; BME 13-1998(Temp),
f. & cert. ef. 8-6-98 thru 2-2-99; BME 14-1998, f. & cert. ef. 10-26-98;
BME 16-1998, f. & cert. ef. 11-24-98; BME 13-1999, f. & cert. ef. 7-23-99;
BME 14-2000, f. & cert. ef. 10-30-00; BME 11-2001, f. & cert. ef. 10-30-01;
BME 9-2002, f. & cert. ef. 7-17-02; BME 10-2002, f. & cert. ef. 7-22-02;
BME 1-2003, f. & cert. ef. 1-27-03; BME 12-2003, f. & cert. ef. 7-15-03;
BME 4-2004, f. & cert. ef. 1-27-04; BME 11-2004(Temp), f. & cert. ef. 4-22-04
thru 10-15-04; BME 12-2004(Temp), f. & cert. ef. 6-11-04 thru 12-8-04; BME 21-2004(Temp),
f. & cert. ef. 11-15-04 thru 4-15-05; BME 2-2005, f. & cert. ef. 1-27-05;
BME 5-2005, f. & cert. ef. 4-21-05; BME 9-2005, f. & cert. ef. 7-20-05;
BME 18-2006, f. & cert. ef. 7-25-06; BME 22-2006, f. & cert. ef. 10-23-06;
BME 7-2007, f. & cert. ef. 1-24-07; BME 11-2007, f. & cert. ef. 4-26-07;
BME 24-2007, f. & cert. ef. 10-24-07; BME 11-2008, f. & cert. ef. 4-24-08;
BME 19-2008, f. & cert. ef. 7-21-08; BME 10-2009, f. & cert. ef. 5-1-09;
BME 13-2009, f. & cert. ef. 7-20-09; BME 18-2009, f. & cert. ef. 10-23-09;
BME 22-2009(Temp), f. & cert. ef. 10-23-09 thru 4-15-10; BME 5-2010, f. &
cert. ef. 1-26-10; BME 8-2010(Temp), f. & cert. ef. 4-26-10 thru 10-15-10; BME
12-2010, f. & cert. ef. 7-26-10; BME 18-2010, f. & cert. ef. 10-25-10; OMB
1-2011, f. & cert. ef. 2-11-11; OMB 5-2011, f. & cert. ef. 4-8-11; OMB 8-2011,
f. & cert. ef. 4-25-11; OMB 15-2012, f. & cert. ef. 4-17-12; OMB 30-2012,
f. & cert. ef. 10-22-12; OMB 11-2013, f. & cert. ef. 4-5-13; OMB 14-2014,
f. & cert. ef. 10-8-14; OMB 5-2015, f. & cert. ef. 4-3-15; OMB 11-2015,
f. & cert. ef. 10-13-15

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