**Year:** 

### 2013

**Did You Receive a Flight Request But Declined to**  **Accept it? Aircraft** 

**N-Num ber**  **Time of Day of Dispatch**

**(if request accepted) Total Flight**  **Time (decim**  **al) IFR Tim**  **e**

**(decim al)**  **Helicopter Base**

**Location (at tim**  **e of flt.) Aircraft NOT directly** 

**dispatched and arrived at a scene but did NOT transport** 

**patients** 

# Helicopter Air Ambulance (HAA) Operator Reporting Data

**January 1 through March 31 Operator/Company Name:**  

# As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below Where and A** **s A ppropriate**  **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 Act unless that collection 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, searching existing data 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 aspect of this collection of inform ation, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW , W ashington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.
**Operator Certificate Designator:** 

## Data Submission: A **ccepted/Flow n HA**  **A Flights - Data Entry**  **Form For Each HA** 

**A 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)**  

# Helicopter Air Ambulance (HAA) Operator Reporting Data As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below** **Where and A s A**  **ppropriate Note: Cells With A** 

**Red Triangle in the Upper Right Corner Have Mouse-Over Guidance** 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 Act unless that collection Public reporting for this collection of information is estimated to be approximately 4-16 hours per response, including the time for reviewing instructions, searching existing data 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 aspect of this collection of **Flight Type Selection Options**



## Data Submission: A**ccepted/Flow n HA**  **A Flights - Data Entry**  **Form Year:**  

### 2013

**Did You Receive a Flight Request But Declined to**  **Accept it? Aircraft** 

**N-Num ber**  **Time of Day of Dispatch**

**(if request accepted) Total Flight**  **Time (decim**  **al) IFR Tim**  **e**

**(decim al)**  **Helicopter Base**

**Location (at tim**  **e 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: A **ccepted/Flow n HA**  **A Flights - Data Entry**  **Form For Each HA** 

**A Operation, Fill in the Requested Information Below** 



# Helicopter Air Ambulance (HAA) Operator Reporting Data

**Ap ril 1 through June 30**  **Operator/Company Name:** 

# As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below Where and A** **s A ppropriate**  **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 Act unless that collection 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, searching existing data 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 aspect of this collection of inform ation, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW , W ashington, 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**



## Data Submission: A**ccepted/Flow n HA**  **A Flights - Data Entry**  **Form** 

# Helicopter Air Ambulance (HAA) Operator Reporting Data As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below** **Where and A s A**  **ppropriate Note: Cells With A** 

**Red Triangle in the Upper Right Corner Have Mouse-Over Guidance** 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 Act unless that collection 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, searching existing data 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 aspect of this collection of**Year:** 

### 2013

**Did You Receive a Flight Request But Declined to**  **Accept it? Aircraft** 

**N-Num ber**  **Time of Day of Dispatch**

**(if request accepted) Total Flight**  **Time (decim**  **al) IFR Tim**  **e**

**(decim al)**  **Helicopter Base**

**Location (at tim**  **e of flt.) Aircraft NOT directly** 

**dispatched and arrived at a scene but did NOT transport** 

**patients** 

# Helicopter Air Ambulance (HAA) Operator Reporting Data

**July 1 through September 30 Operator/Company Name:**  

# As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below Where and A** **s A ppropriate**  **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 Act unless that collection 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, searching existing data 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 aspect of this collection of inform ation, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW , W ashington, DC 20591, Attn: Information Collection Clearance Officer, AES-200.
**Operator Certificate Designator:** 

## Data Submission: A **ccepted/Flow n HA**  **A Flights - Data Entry**  **Form For Each HA** 

**A 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)**  

# Helicopter Air Ambulance (HAA) Operator Reporting Data As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below** **Where and A s A**  **ppropriate Note: Cells With A** 

**Red Triangle in the Upper Right Corner Have Mouse-Over Guidance** 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 Act unless that collection 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, searching existing data 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 aspect of this collection of **Flight Type Selection Options**



## Data Submission: A**ccepted/Flow n HA**  **A Flights - Data Entry**  **Form Year:**  

### 2013

**Did You Receive a Flight Request But Declined to**  **Accept it? Aircraft** 

**N-Num ber**  **Time of Day of Dispatch**

**(if request accepted) Total Flight**  **Time (decim**  **al) IFR Tim**  **e**

**(decim al)**  **Helicopter Base**

**Location (at tim**  **e 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: A **ccepted/Flow n HA**  **A Flights - Data Entry**  **Form For Each HA** 

**A Operation, Fill in the Requested Information Below** 



# Helicopter Air Ambulance (HAA) Operator Reporting Data

**October 1 through December 31 Operator/Company Name:**  

# As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below Where and A** **s A ppropriate**  **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 Act unless that collection 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, searching existing data 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 aspect of this collection of inform ation, including suggestions for reducing this burden to the FAA at: 800 Independence Ave SW , W ashington, 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**



## Data Submission: A**ccepted/Flow n HA**  **A Flights - Data Entry**  **Form** 

# Helicopter Air Ambulance (HAA) Operator Reporting Data As Mandated by the FAA Modernization and Reform Act of 2012, Title III, Section 306 **Please Fill In White A reas Below** **Where and A s A**  **ppropriate Note: Cells With A** 

**Red Triangle in the Upper Right Corner Have Mouse-Over Guidance** 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 Act unless that collection 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, searching existing data 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 aspect of this collection ofYearQuarter January 1 to March 31
April 1 to June 30 July 1 to September 30 October 1 to December 31