HAZARD REPORTING FORM Employee Name (optional) Location Date MM slash DD slash YYYY Time of Occurrence : Hours Minutes AM PM AM/PM Type of Report Occurrence Hazard Other Other Personnel Involved Type of Occurrence (Check One) Maintenance Flight Other Flight Related? (Check One) Yes No Type of Flight (describe) Aircraft Type and N-number Environmental conditions (describe): i.e., temperature, wind, visibility, precip, lighting, etc.What factors contributed? Procedures Tools Testing Repair/Troubleshoot Manuals Inspection Installation Shop Conditions Avionics Logbook Maintenance Weather Air frame Other (Describe) Engine Parts Lighting Flight Following Injuries or fatalities? Yes No Description of the OccurrenceRecommendations to Prevent RecurrenceName and Signature (Optional) Date MM slash DD slash YYYY Please attach any files/images (optional) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 32 MB. Δ
