Year: 2013

Did You Receive a Flight 

Request But Declined to 

Accept it? 

Aircraft

N-Number 

Time of Day of Dispatch 

(if request accepted)

Total Flight 

Time

(decimal)

IFR Time 

(decimal)

Helicopter Base 

Location (at 

time of flt.)

Aircraft NOT directly 

dispatched and arrived at a 

scene but did NOT transport 

patients

Helicopter Air Ambulance (HAA) Operator Reporting 

January 1 through March 31

Operator/Company Name:

As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Se

Please Fill In White Areas Below Where and As Appropriate

Note: Cells With A Red Triangle in the Upper Right Corner Have Mouse-Over Guidance

 dba (doing business as):

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Ac

of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 4-16 hours per response, including the time for reviewing instructions, s

sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory per The FAA Modernization and Reform Act of 2012. Send comments regarding this burden estimate or any other asp

information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

 Operator Certificate Designator: 

Data Submission: Accepted/Flown HAA Flights - Data Entry Form

For Each HAA Operation, Fill in the Requested Information Below

NOTE: Mouse-over cells with red triangles for further guidance

 Reporting Period:

 (S) Scene Response

 (I) Interfacility Transport

 (O) Organ Transport

OMB CONTROL NUMBER 2120-XXXX

 (F) Ferry Flight

 (R) Repositioning Flight

Flight Type (see 

Flight Type 

Selection options 

above)

Reporting Data

12, Title III, Section 306

riate

ver Guidance

irements of the Paperwork Reduction Act unless that collection 

ding the time for reviewing instructions, searching existing data 

ng this burden estimate or any other aspect of this collection of 

Flight Type Selection Options

Entry Form

Year: 2013

Did You Receive a Flight 

Request But Declined to 

Accept it? 

Aircraft

N-Number 

Time of Day of Dispatch 

(if request accepted)

Total Flight 

Time

(decimal)

IFR Time 

(decimal)

Helicopter Base 

Location (at 

time of flt.)

Aircraft NOT directly 

dispatched and arrived at a 

scene but did NOT transport 

patients

NOTE: Mouse-over cells with red triangles for further guidance

 Reporting Period:

 (S) Scene Response

 (I) Interfacility Transport

 (O) Organ Transport

 Operator Certificate Designator: 

Data Submission: Accepted/Flown HAA Flights - Data Entry Form

For Each HAA Operation, Fill in the Requested Information Below

Helicopter Air Ambulance (HAA) Operator Reporting 

April 1 through June 30

Operator/Company Name:

As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Se

Please Fill In White Areas Below Where and As Appropriate

Note: Cells With A Red Triangle in the Upper Right Corner Have Mouse-Over Guidance

 dba (doing business as):

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Ac

of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 4-16 hours per response, including the time for reviewing instructions, s

sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory per The FAA Modernization and Reform Act of 2012. Send comments regarding this burden estimate or any other asp

information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

OMB CONTROL NUMBER 2120-XXXX

 (F) Ferry Flight

 (R) Repositioning Flight

Flight Type (see 

Flight Type 

Selection options 

above)

Flight Type Selection Options

Entry Form

Reporting Data

12, Title III, Section 306

riate

ver Guidance

irements of the Paperwork Reduction Act unless that collection 

ding the time for reviewing instructions, searching existing data 

ng this burden estimate or any other aspect of this collection of 

Year: 2013

Did You Receive a Flight 

Request But Declined to 

Accept it? 

Aircraft

N-Number 

Time of Day of Dispatch 

(if request accepted)

Total Flight 

Time

(decimal)

IFR Time 

(decimal)

Helicopter Base 

Location (at 

time of flt.)

Aircraft NOT directly 

dispatched and arrived at a 

scene but did NOT transport 

patients

Helicopter Air Ambulance (HAA) Operator Reporting 

July 1 through September 30

Operator/Company Name:

As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Se

Please Fill In White Areas Below Where and As Appropriate

Note: Cells With A Red Triangle in the Upper Right Corner Have Mouse-Over Guidance

 dba (doing business as):

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Ac

of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 4-16 hours per response, including the time for reviewing instructions, s

sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory per The FAA Modernization and Reform Act of 2012. Send comments regarding this burden estimate or any other asp

information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

 Operator Certificate Designator: 

Data Submission: Accepted/Flown HAA Flights - Data Entry Form

For Each HAA Operation, Fill in the Requested Information Below

NOTE: Mouse-over cells with red triangles for further guidance

 Reporting Period:

 (S) Scene Response

 (I) Interfacility Transport

 (O) Organ Transport

OMB CONTROL NUMBER 2120-XXXX

 (F) Ferry Flight

 (R) Repositioning Flight

Flight Type (see 

Flight Type 

Selection options 

above)

Reporting Data

12, Title III, Section 306

riate

ver Guidance

irements of the Paperwork Reduction Act unless that collection 

ding the time for reviewing instructions, searching existing data 

ng this burden estimate or any other aspect of this collection of 

Flight Type Selection Options

Entry Form

Year: 2013

Did You Receive a Flight 

Request But Declined to 

Accept it? 

Aircraft

N-Number 

Time of Day of Dispatch 

(if request accepted)

Total Flight 

Time

(decimal)

IFR Time 

(decimal)

Helicopter Base 

Location (at 

time of flt.)

Aircraft NOT directly 

dispatched and arrived at a 

scene but did NOT transport 

patients

NOTE: Mouse-over cells with red triangles for further guidance

 Reporting Period:

 (S) Scene Response

 (I) Interfacility Transport

 (O) Organ Transport

 Operator Certificate Designator: 

Data Submission: Accepted/Flown HAA Flights - Data Entry Form

For Each HAA Operation, Fill in the Requested Information Below

Helicopter Air Ambulance (HAA) Operator Reporting 

October 1 through December 31

Operator/Company Name:

As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Se

Please Fill In White Areas Below Where and As Appropriate

Note: Cells With A Red Triangle in the Upper Right Corner Have Mouse-Over Guidance

 dba (doing business as):

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Ac

of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 4-16 hours per response, including the time for reviewing instructions, s

sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory per The FAA Modernization and Reform Act of 2012. Send comments regarding this burden estimate or any other asp

information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.

OMB CONTROL NUMBER 2120-XXXX

 (F) Ferry Flight

 (R) Repositioning Flight

Flight Type (see 

Flight Type 

Selection options 

above)

Flight Type Selection Options

Entry Form

Reporting Data

12, Title III, Section 306

riate

ver Guidance

irements of the Paperwork Reduction Act unless that collection 

ding the time for reviewing instructions, searching existing data 

ng this burden estimate or any other aspect of this collection of 

YearQuarter

January 1 to March 31

April 1 to June 30

July 1 to September 30

October 1 to December 31