【付録⑥】

⽶国連邦航空局（FAA）による認定基準
依存症から回復したパイロットを乗務復帰な状態に戻すプロセス

回復したパイロットをFAA認証プロセスに提出するかどうかは、最終的にはメディカル・スポンサーが決定します。このスポンサーとは、HIMSトレーニングを受け、FAAからこの任務を遂⾏することを承認されたAME（Aviation Medical Examiner＝航空⾝体検査指定医）です。多くの場合、関係する航空会社の指定医がこの任務を遂⾏しますが、他の航空会社は独⽴したAMEに依頼します。
⽬標は、パイロットが安定した回復状態にあり、治療にあたっている専⾨家が⾶⾏状態に戻る準備ができていると合意することです。急速に事を進めることは有益ではなく、回復には時間の経過が必要であることが多いです。以下のタイム
ラインチャートは、FAA提出プロセスのさまざまな要素を理解するのに役⽴ちます。
各ステップの時間は概算であることに留意してください。しかし、各ステップは、FAAに提出するパッケージに含まれなければならない要素です。それらを個別に検討します。

評価
FAAは、多軸評価を⽂書化した正式な14CFR67診断（航空⾝体検査基準）を要求しています。診断評価が⼊院治療施設にて⾏われた場合は、完全な病歴と診断の根拠が含まれていなければなりません。

⼊院治療
パイロットが治療施設に直接⼊院した場合は、上記で検討した初期評価の元となります。そうでない場合は、治療施設が診断を確認するための評価を⾏います。これは通常、病歴と⾝体検査の⼀部であり、診断と治療に関する推奨事項で締めくくられます。
治療プログラムの間、各患者の個⼈記録とグループ記録が作成されます。評価を⾏う⼼理学者や精神科医、そしてFAAは、提出書類の⼀部としてこれらの記録を求めます。また、⼼理テストの結果や個⼈的な情報も必要となります。
医療機関からは完全なデータを提供することを求めなければならず、定型⽂では認められません。
パイロットが施設を退所する際には、退所時の診断書を作成します。この診断書には、パイロットの居住地域での必要な継続治療を推奨する内容が書かれてなくてはなりません。これには、集中外来療法（IOP）、個⼈療法、断酒会
23

（常時）、アフターケアグループ（常時）、および必要に応じて家族カウンセリングなどが含まれます。多くの治療センター
では、地元の継続的な治療リソースの特定に責任を持っています。⼊院治療施設がパイロットの⾃宅の近くにあり、同じ施設で継続治療を続けられる場合が望ましい理想的な状況ではあります。

集中的な外来患者または個⼈療法
これは、⼊院プログラムの延⻑線上にあることが多く、パイロットが⼗分な進捗を遂げて週1回のアフターケアグループで⼗分に対応できるようになるまで続けなければなりません。個⼈セラピーは、パイロットが⾶⾏任務に復帰した後も続けることができます。いずれの場合も、パイロットが⾶⾏任務への復帰を勧告できるほど⼗分に進歩した後、FAAに提出するための包括的な診断書が必要となります。この診断書では、パイロットの回復状況をFAAが把握できるように、治療上の問題点や進捗状況について⼗分な詳細を記載する必要があります。

アフターケア・アルコールアノニマス、断酒会
アフターケアグループは、乗務に復帰した後の節制の基礎となるもので、条件付き航空⾝体検査証明において義務付けられます。FAAに提出する書類には、参加状況や進捗状況をきちんとまとめておく必要があります。FAAは、パイロットが条件付き航空⾝体検査証明の交付期間中、少なくとも半数以上の会合に出席することを期待しています。FAA提出書類にアフターケア・プログラムを記載しないと、FAA認証に遅れが⽣じることとなります。
アルコールアノニマス（AA）は、FAAが公式に義務付けているものではありませんが、もう⼀つの基礎となるものです。
アフターケア報告書では、パイロットのAAへの出席状況を確認し、パイロットに恒久的なスポンサーがいることを⽂書化する必要があります。AAから直接必要な書類はありません。

ピアサポートとスポンサー
ピアサポートとスポンサーの双⽅が理解し合い、トレーニングを受け、話し合いがどのように⾏われるのかを理解する必要があります。当該乗員は、毎⽉1回の話し合いが⾏われ、スポンサーが⽉例報告書の提出先を理解していることを確認する責任があります。AME は、スポンサーが配置されていることを AME の診断書に記録する必要があります。
⼼理学的・精神医学的検査(P&P)
FAAは、全国の⼼理学者と精神科医の双⽅を指定します。これらによる検査は、前述の⼿順がすべて整い、パイロットが乗務に復帰する準備ができていることに全員が同意するまで予定すべきではありません。記録の写しを評価の前に双⽅に送られるべきです。これは⾮常に⾯倒で、鋭敏な判定となります。慢性的な使⽤障害による認知機能障害が残っている場合は、パイロットはP&Pを受けるべきではありません。回復のためにはより多くの時間が必要です。パイロットが確実に回復していない場合は乗務復帰する前に、より多くの治療や時間が必要であると判断されることが多いでしょう。そのため、数ヶ⽉後に再度検査を⾏う必要があります。
FAAの審査・提出書類
これは、症例を提出する前の最終審査です。AMEは、パイロットが回復したと認めるまでは提出プロセスを保留する完全な裁量権を持っています。FAAに提出する書類には、以下の情報が含まれます。
24

l

診断記録（もし回復治療とは別の場合）

l

⼊院中の治療記録⼀式

l

IOP（集中外来プログラム＝主に摂⾷障害、双極性障害、単極性うつ病、⾃傷⾏為、解毒に依存しない薬物依存症の治療に使⽤される⼀種の治療サービスおよびサポートプログラム）または個⼈療法の概要lアフターケアグループの概要とスケジュールl

完全な⼼理学的・精神医学的診断書

l8500-8（FAA航空⾝体検査証明申請書）

l

メディカルスポンサーからの概要
AMEは、すべての記録を慎重に確認し、⾒過ごされている問題がないことを確認しなければなりません（例︓アルコー

ル治療記録の奥深くにあるメモに対処されていないコカインの使⽤が記載されているなど）。メディカルスポンサーからの診断書は、AMEが本当にパイロットの状況を正確に把握していることをFAAが判断し、⾶⾏状態への復帰を合法的に⽀持するのに⼗分な詳細を含んでいなければなりません。パイロットは、航空⾝体検査証明の資格を有していなければなりません。この症例は、署名された書類を添付して、連邦航空⾝体検査部署のオフィスに送られなければなりません。
⾝体検査証明条件付き⾝体検査証明申請書は、⾮常に具体的な要求事項が記載されています。パイロットは、申請書の各条項が満たされていることを確認する責任があります。AMEは、いつでも⾝体検査証明を取り消すことができます。⾶⾏任務への復帰は、回復したパイロットにとって特に脆弱な時期となります。習慣的な⾏動を⽀えていた環境に戻るということは、より⾼い意識が必要となります。

25

FAA CERTIFICATION AID - HIMS Drug and Alcohol - INITIAL (Page 1 of 5)(Updated 01/27/2021)

The following information is to assist your treating physician/provider who may be unfamiliar with FAA medical
certification requirements. It lists the ABSOLUTE MINIMUM information required by the FAA to make adetermination on an airman medical certificate. You should strongly consider taking a copy to each evaluator so they
understand what specific information is needed in their report to the FAA. If each item is not addressed by thecorresponding provider there may be a delay in the processing of your medical certification until that information issubmitted. Additional information such as clinic notes or explanations should also be submitted, as needed.
ALL REPORTS MUST BE CURRENT (WITHIN THE LAST 90 DAYS) FOR FAA PURPOSES.

REPORT FROMMUST SPECIFICALLY ADDRESS OR STATE THE FOLLOWINGHIMS AMECHECKLIST

1. Using the HIMS-Trained AME Checklist – Drug and Alcohol Monitoring INITIAL Certification, comment on anyitems that fall into the shaded category on the Checklist.

#1 HIMS AMEREPORT(narrative)

1. Must be a face-to-face, in-person evaluation performed by the HIMS-trained AME.
2. List of the items/documents reviewed:
a. Prior SI authorizations, if issued by the FAA;
b. Verify if you were provided with and reviewed a complete copy of the airman’s FAA Medical file sent toyou by the FAA; andc. Include list of collateral contact(s) used to verify history, if any.
3. Describea. How the case was initially identified. Circumstances regarding the pilot’s entry into the HIMS program;b. Description of the history of the addiction problem;c. Participation in aftercare groups, if any;d. Participation in support groups (AA, BOAF, other);e. History of ER visits;
f. Previous psychiatric hospitalizations, treatments, or suicide attempts; andg. Hospital/treatment discharge summary.
4. Compliance History
a. Any evidence (such as a positive test) or concern the airman has not remained abstinent;b. Any evidence or concern the airman has not been compliant with the recovery program;c. If you do not agree with the supporting documents or if you have additional concerns not noted in thedocumentation, please discuss your observations or concerns; andd. Describe how the airman is doing in the program and if he/she is engaged in recovery.
5. Summarize your aeromedical impression and evaluation as a HIMS AME based on the face-to-face evaluation
AND review of the supporting documents.
a. Do you recommend a Special Issuance for this airman;
b. Do you agree to serve as the airman’s HIMS AME and follow this airman per FAA policy; andc. Do you agree to immediately notify the FAA (at 405-954-4821) of any change in condition, deterioration,or stability and/or if there is any positive drug or alcohol testing?
6. Any NEW condition(s) that would require Special Issuance? (Do not include any new CACI qualified conditions.)

The airman must
establish with a
HIMS-trained AME if
monitoring isrequired.

If using Huddle, submit the following as INDIVIDUAL PDFs:
HIMS AME Checklist;
HIMS trained AME written report (narrative)
HIMS AME Data Sheet
Drug and/or Alcohol Treatment Records
Psychiatrist Evaluation
Neuropsychologist Evaluation and Raw Test Data
Additional Records - all other supporting documentation that you reviewed
Submit all the information as ONE PACKAGE (via Huddle or mailed to the appropriate address on the HIMS-Trained
AME Checklist.) Review for certification WILL BE DELAYED if package is incomplete.

26

FAA CERTIFICATION AID - HIMS Drug and Alcohol - INITIAL (Page 2 of 5)#2 HIMS AMEDATASHEET*

1. A copy of the sheet printed after entering information via www.himsdatasheet.com. (*only for first andsecond class airmen.)#3 DRUG AND/OR
ALCOHOL
TREATMENTRECORDS

1. Include any applicable psychotherapy notes, therapist follow-up reports, social worker reports, AA sponsor contact,etc.
2. Include all the original records summarized in the HIMS AME Report above.

#4 PSYCHIATRISTEVALUATIONThe report must include at a minimum:

1st and 2nd classcommercial airmen
will require a HIMS
trained psychiatrist*
to perform thisevaluation in mostcases.
Most others will
require a board
certified psychiatrist* To find a HIMS
psychiatrist, the airman
should FIRST establish
with a HIMS-trained AME
and should refer to theirletter to determine whatlevel of evaluation isrequired.
.

1. List of the items/documents reviewed.
a.
Verify if you were provided with and reviewed a complete copy of the airman’s FAA medical file sent toyou by the FAA; andb.
Include list of collateral contact(s) used to verify history, if any.
2. Summary of the above records. Were the records clear and in sufficient detail to permit a satisfactory evaluation of
the nature and extent of any previous mental disorders?
Clinical interview that covers the following:
3. Family history of drug and alcohol or mental health issues.
4. Developmental history.
5. Past medical history and medical problems such as blackouts, memory problems; stomach, liver, cardiovascular
problems, or sexual dysfunction.
6. Psychiatric history, if any. Include diagnosis, treatment, and hospitalizations.
a. Personal history of anxiety, depression, insomnia; and/orb. Suicidal thoughts or attempts.
7. Alcohol and/or Drug use history:a. Include any treatment or hospitalizations; andb. The current status of drug or alcohol use (what used, how often, start/stop dates).
8. Other concerns such as:a. Personality changes (argumentative, combative) or Loss of self-esteem or Isolation;b. Social family problems such as marital separation or divorce;c. Irresponsibility or child/spousal abuse;d. Legal problems such as alcohol-related traffic offenses or public intoxication, assault and battery, etc.;
e. Occupational problems such as absenteeism or tardiness at work; reduced productivity, demotions,frequent job changes, or loss of job;f. Economic problems such as frequent financial crises, bankruptcy, loss of home, or lack of credit; andg. Interpersonal adverse effects such as separation from family, friends, associates, etc.
9. Any other items per the evaluator.
10. Results of any testing that was performed (SASSI, etc.).
11. Mental status examination results.
12. Summary of your findings. Include if you agree or disagree with previous diagnosis or findings from the records
you reviewed and why.
13. Any evidence of drug or alcohol abuse or dependence (if not mentioned above).
14. Summarize clinical findings and status of the airman.
When appropriate, provide specific information about the quality of recovery, including the period of total
abstinence.
15. List the DSM diagnosis, if any. (if none, that should be stated).
16. Specifically mention if any of the following regulatory components are present or not:a. Increased tolerance;b. Manifestation of withdrawal symptoms;c. Impaired control of use;d. Continued use despite damage to physical health or impairment of social, personal, or occupationalfunctioning;e. Any evidence of any other personality disorder, neurosis, or mental health condition; and/or
f. Use of a substance in a situation in which that use was physically hazardous.
17. Give recommendations for any additional treatment or monitoring, if applicable.
18. Any additional concerns or comments.

27

FAA CERTIFICATION AID - HIMS Drug and Alcohol - INITIAL (Page 3 of 5)#5
NEUROPSYCHOLOGISTEVALUATION AND
RAW TEST DATA*

For complete details, see the Neuropsychological Evaluation
section of the Specifications for Psychiatric and Neuropsychological
Evaluations for Substance Dependence/Abuse.

*CogScreen-AE resultsandneurocognitive evaluation

The neuropsychologist report MUST address:
1. Qualifications: State your certifications and pertinent qualifications.
2. Records review: What documents were reviewed, if any?
a. Specify clinic notes and/or notes from other providers or
hospitals; andb. Verify if you were provided with and reviewed a complete
copy of the airman’s FAA medical file.
3. Results of clinical interview: Detailed history regarding
psychosocial or developmental problems; academic and employment
performance; family or legal issues; substance use/abuse (includingtreatment and quality of recovery); aviation background andexperience; medical conditions and all medication use; andbehavioral observations during the interview and testing. Include anyother history pertinent to the context of the neuropsychological testingand interpretation.
4. Mental status examination
5. Testing results:
a. CogScreen-Aeromedical Edition (CogScreen-AE); andb. Remainder of the core test battery.
6. Interpretation:a. The overall neurocognitive status of the airman;
b. Clinical diagnosis(es) suggested or established based on
testing, if any;c. Discuss any weaknesses or concerning deficiencies that may
potentially affect safe performance of pilot or aviation-related
duties, if any;d. Discuss rationale and interpretation of any additional testingthat was performed; and include
e. Any other concerns.
7. Recommendations: Additional testing, follow-up testing, referral for
medical evaluation (e.g., neurology evaluation and/or imaging),
rehabilitation, etc.
Submit report along with the CogScreen-AE computerized summary
report (approximately 13 pages) and summary score sheet for ALL
additional testing performed.

28

FAA CERTIFICATION AID - HIMS Drug and Alcohol - INITIAL (Page 4 of 5)#6 ADDITIONAL RECORDS
AFTERCARE REPORT(Group)

Progress report should include:
1. If the airman is continuing to participate in abstinence-based sobriety;
2. How often the airman attends (weekly or per Authorization Letter); and3. Agreement to immediately notify the HIMS AME if there are any changes or deterioration in the airman’scondition.

AIRLINE REPORTS

Must attest, to the best of their knowledge, the airman’s continued total abstinence from drugs or alcohol.

Peer Pilot (from employer,ALPA, etc.)
Chief Pilot, Flight Operation
Supervisor, or Airline
Management Designee*

Monthly reports must address:
1. The airman’s performance and competence;
2. Crew interaction;
3. Mood (if available); and4. Presence or absence of any other concerns.

* If the airman is 1st or 2nd class andemployed by an air carrier.

Combine all monthly reports into ONE PDF if submitting via Huddle.

AIRMANPERSONAL
STATEMENT DRUG AND
ALCOHOL(D&A)

1. Detailed typed personal statement from you that describes the offense(s):a. What type of offense occurred;b. What substance(s) were involved;c. State or locality or jurisdiction where the incident occurred;d. Date of the arrest, conviction and/or administrative action;e. Description of circumstances surrounding the offense; andf. Describe the above for each alcohol incident. If no other incidents, this should be stated.
2. Your past, present, and future plans for alcohol or drug use:a. When did you start drinking? How much? How often?;b. How much, how often were you drinking at the time of the incident(s);c. How much, how often do you drink now? If abstinent, state date abstinence started;d. Any negative consequences (legal complications or medical complications such as blackouts,pancreatitis, or ER visits); ande. Include any other alcohol or drug offenses (arrests, convictions, or administrative actions), even if
they were later reduced to a lower sentence.
3. Treatment programs you attended ever in your life (if none, this should be stated).
a. Dates of treatment;b. Inpatient, outpatient, other; andc. Name of treatment facility
1. Current recovery program (if any). If AA or another program, list name of program and frequency
attended.
If not in a recovery program, this should be stated.

DRUG OR ALCOHOLTESTING

1. Must be random, unannounced drug/alcohol testing. (Urine EtG/EtS, PEth testing or a mobile alcohol
monitoring system are preferred.)
2. Must state if the testing is performed by:
HIMS AME;
Air Carrier testing program/office. Air Carrier must immediately notify the HIMS AME of any positive
test HIMS AME may require additional testing to supplement the testing conducted by the Air Carrier; orOther, such as return to duty testing from a substance abuse professional or a DOT/FAA Drug
Abatement Program.
3. Drug and/or alcohol testing results summarized, how often tested, how many tests performed to date.
a. Positive test results – submit the actual report.
b. Negative test results should be reported in the HIMS AME Report.

29

FAA CERTIFICATION AID - HIMS Drug and Alcohol - INITIAL (Page 5 of 5)
DUI RECORDS

Court Records
1. Police/investigative report from dates of incident(s). It should describe the circumstances surroundingthe offense and any field sobriety tests that were performed;
2. Court records, if applicable; and3. Military records if event(s) occurred while the applicant was a member of the U.S. armed forces. It should
include military court records, records of non-judicial punishment, and military substance abuse records.
Driving record/Department of Motor Vehicles (DMV) Records
4. List every state/principality/location and dates you have held a driver’s license in the past 10 years;
5. Submit a complete copy of your driving records from each of these for the past 10 years; and6. Blood Alcohol Concentration (BAC) from any alcohol offense. It may be listed in a hospital report, a police
report or investigative report.
a. This will be either a breathalyzer test or a blood test.
b. Attach copies of any additional drug testing that performed.

MEDICAL RECORDS

List any other medical records relevant to this case.

SI ADDITIONALREPORTS

1. Submit any reports required by a current Authorization for Special Issuance (SI); and/or
2. Any reports for a new condition that may require SI (or AME is instructed to defer).

30