(1) All persons, including licensees, corporations, organizations, health care facilities, and state or local governmental agencies shall report to the board any conviction, determination, or finding that an occupational therapist or an occupational therapy assistant has committed an act which constitutes unprofessional conduct as established in RCW 18.130.180 and shall report information which indicates that an occupational therapist or occupational therapy assistant may not be able to practice occupational therapy with reasonable skill and safety to consumers as a result of a mental or physical condition.

(2) All required reports shall be submitted to the board as soon as possible, but no later than sixty days after a conviction, determination, or finding is made or information is received.

(3) A report shall contain the following information if known:

(a) The name, address, and telephone number of the person making the report.

(b) The name, address, and telephone numbers of the occupational therapist or occupational therapy assistant being reported.

(c) The case number of any patient or the name of the patient whose treatment is a subject of the report.

(d) A brief description or summary of the facts which gave rise to the issuance of the report, including dates of occurrences.

(e) If court action is involved, the name of the court in which the action is filed along with the date of filing and cause number.

(f) Any further information which would aid in the evaluation of the report.