Form FS-5700-20a Helicopter Pilot Qualifications and Approval Record

---

Overview

FS 5700-20a
Evaluation Form
Burden Statement
Instructions

---

Sheet 1: FS 5700-20a

FS-5700-20a (Rev. 03/2008)

OMB 0596-0015 (Omission of Exp. date approved by OMB)

Contract Number:

USFS:

HELICOPTER PILOT QUALIFICATIONS AND APPROVAL RECORD

DOI:

(Reference FSH 5709.12 )

SECTION I - Pilot Information (to be filled out by pilot seeking approval)

1. Name (Last, First, Middle Initial)

2. Date of Birth

3. Primary Telephone Number

4. Home Address (Street, City, State & ZIP Code)

5. E-Mail Address

6. Employed By

7. Address

8. Telephone No.

9. Employed Since

10. Previous Employer

11. Address

12. Telephone No.

13. Period Employed

to

14. Previous Employer

15. Address

16. Telephone No.

17. Period Employed

to

18. Medical Certificate:

Class

Date

19. Most Recent Interagency Pilot Card Information

Limitations:

Date Issued:

Expiration:

Insp. Name:

Agency:

20. Airman Certificate:

Commercial

ATP

CFI

21. Most Recent Interagency Flight Evaluation Information

Number:

Other Ratings:

Date Evaluation Conducted:

Insp. Name:

Agency:

Helicopter Pilot-in-Command

PIC

22. Aircraft accidents / FAA violations within the last 5 years:

No

Yes

Flight Time & Type of Flight

Hours

(if Yes, explain in box 38)

Only

23. Has a Previous Interagency Pilot Card been:

Denied

Suspended

Revoked

24. Total Helicopter PIC

----

----

----

----

----

(Check those that apply and explain in box 40)

25. Weight Class

----

----

----

----

----

(a)

(b)

(c ) PIC Hours for Column "a" A/C

under 7,000

----

----

----

----

----

Make, Model & Series

Are you Type Rated

Aircraft Total

Mountainous Terrain

Preceding 12 months

7,000 to 12,500

----

----

----

----

----

seeking approval in

for column "a" A/C

over 12,500

----

----

----

----

----

33.

Yes

No

26.

Turbine Engine

(PIC helicopter)

34.

Yes

No

27.

Reciprocating Engine

(PIC helicopter)

35.

Yes

No

28.

Preceding 12 months

(PIC helicopter)

36.

Yes

No

29.

Preceding 90 days

(PIC helicopter)

37.

Yes

No

30.

Mountainous Terrain

(PIC helicopter)

38.

Last FAA Part 135 Evaluation: (attach copy)

Date:

Make & Model:

31.

NVG Operations

(PIC helicopter)

39.

Last Bi-Annual Flight Review: (attach copy)

Date:

Make & Model:

32.

Offshore

(PIC helicopter)

40. Accident / Incident Explanation, Comments;

I certify that the information listed on this form is true and correct. In addition, I certify that I have read the statements

attached to this form covering information pursuant to Public Law 93-579 (Privacy Act of 1974)

41. Pilot Signature

42. Date

SECTION II - Approvals (to be filled out by Pilot Inspectors only)

1. Special Use Mission Approved For: (Inspector Shall Initial)

a.(

) Reconnaissance / Surveillance

h.(

) Aerial Ignition: PSD

o.(

) Short-Haul

b.(

) Fire Suppression / Helitack

i.(

) Aerial Ignition: Torch

p.(

) ACETA

c.(

) External Load / Sling Operations (belly hook)

j.(

) Rappel Operations

q.(

) Float Operations (Fixed)

d.(

) Water / Retardant Delivery

k.(

) Snow Operations (Deep Snow)

r.(

) Platform landing, Offshore

e.(

) Longline - VTR (150 feet)

l.(

) Animal Inventory / Classification

s.(

) Night Vision Goggle Operations

f.(

) Snorkel - VTR

m.(

) Designated "Pilot Trainer"

t.(

) Other

g.(

) Mountainous Terrain Flight

n.(

) "Trainee Only" Pilot

u.(

) Other

2. Flight Evaluation:

Administered

Not Administered

3. Make / Model / Series Aircraft Approved For

4. Signature (Pilot Inspector)

5. Agency

6. Issue Date

7. Expiration Date

8. Make / Model / Series Aircraft Approved For

9. Signature (Pilot Inspector)

10. Agency

11. Issue Date

12. Expiration Date

13. Remarks

---

Sheet 2: Evaluation Form

SECTION III - Helicopter Pilot Evaluation / Qualification Check (To be filled out prior to the administration of a flight evaluation)

1. Category of Evaluation (Pilot Inspector check appropriate box)

2. Type of Evaluation Administered (Pilot Inspector check appropriate box)

Initial

Recurrent

Interim

Post-Accident

IFR

VFR

3. Pilot Name (Last, First, Middle Initial)

4. Competency: Make and Model

5. Knowledge: Make and Model

6. Employed By

7. Location of Flight Evaluation

8. Flight Time & Aircraft N Number

N-

Pilot Statement: I have been briefed on the reason for this evaluation flight and understand that I will remain as pilot-in-command of the aircraft throughout the flight and that I may refuse to attempt any maneuver which, in my opinion, may be hazardous or unsafe.

9. Pilot Signature (Sign Prior to Flight)

10. Date

Insert the following letters below each Section (IV thru VI), if applicable

D-Demonstrated Ability

K-Knowledge

U-Unsatisfactory

SECTION IV Equipment Exam - (Oral / Written)

8

Emergency Procedures

1

Aircraft / Pilot Documents

a.

Engine Failure after Takeoff

2

Weight and Balance

b.

Maneuvering with Engine Out

3

Fuel Requirements

c.

Approach and Landing, One Engine Out

4

Systems Operation

d.

System Emergencies

5

Emergency Procedures

e.

Autorotation / Forced Landings

6

Emergency / Survival Equipment

f.

Antitorque Failure

7

Operation / Safety Briefing

g.

Hydraulic Failure

9

Instrument Procedures

SECTION V - Preformance Planning and Preflight

a.

Equipment Check

1

Aircraft Documents

b.

ATC Procedures

2

Manifest and Flight Plan

c.

Navigation / Orientation

3

Aircraft Performance

d.

Holding

4

Load Calculation

e.

Approach-NDB,VOR, DME, LOC, ILS

5

Preflight Procedure

f.

Missed Approach / Circling Approach

6

Use of Check List

g.

Speed, Heading Altitudes

SECTION VI - Flight Evaluation

h.

Automatic Pilot/single Pilot

1

Starting Procedure

i.

Crew Coordination

2

Communication and Navigation Equipment Check

3

Hover Taxi / Ground Taxi

10

Special Use Operations

4

Run-up / Power Check

a.

Reconnaissance / Surveillance

b.

Fire Suppression / Helitack

5

Take-off Operations

c.

External Load / Sling Operations (belly hook)

a.

Normal

d.

Water / Retardant Delivery

Bucket:

Tank:

b.

Crosswind

e.

Longline - VTR (150 feet)

With:

W/O:

Load

c.

Maximum Performance

f.

Snorkel - VTR

d.

Aborted

g.

Mountainous Terrain Flight

h.

Aerial Ignition:

PSD:

Torch:

6

Approach/Landing

i.

Rappel Operations

a.

Wind Evaluation

j.

Snow Operations (Deep Snow)

b.

Helispot Evaluation

k.

Animal Inventory / Classification

c.

Crosswind Approach

l.

Designated "Pilot Trainer"

d.

Rejected Landing / Go-Around

m.

"Trainee Only" Pilot

e.

Winter Ops / Deep Snow Landings

n.

Short-Haul

f.

Pinnacle or Platform

o.

ACETA

g.

Confined Area

p.

Float Operations (Fixed)

h.

Slope Landing

q.

Platform landing, Offshore

r.

Night Vision Goggle Operations

7

Water Operations

s.

Other

a.

Taxiing, Sailing, Docking

b.

Glassy Water / Rough Water

11

Judgment

c.

Takeoff and Landings

12

Shutdown Checklist

SECTION VII - Remarks, Limitations & Approvals (To be filled out by inspector)

1 Remarks, Limitations & Aircraft Approvals (as appropriate)

2 Evaluation Status (Pilot Inspector please initial appropriate status)

3 Expiration Date

4 Signature (Pilot Inspector)

Approved

Disapproved (See Remarks)

---

Sheet 3: Burden Statement

				PRIVACY ACT NOTICE
	Collection and use of the information on this form covered under Privacy Act System of Records USDA/FS-44 (Pilot Qualification Records) and consistent with the provisions of 5 USC 552a (Privacy Act of 1974).
	Purpose and Use - - This information, along with data you may have supplied previously, and information developed by investigation will be for use by such as:
		1. To determine your pilot qualifications to comply with contract specifications.
		2. Transfer to the U.S. Department of Justice in the event of litigation.
		3. Transfer, in the event there is indicated violation or potential violation of a statute, regulation, whether civil, criminal, or regulatory in nature, to the appropriate agency or agencies, whether Federal, State, local, or foreign, charged with the responsibility of investigation or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, order, or license violated or potentially violated
			BURDEN AND NONDISCRIMINATION STATEMENTS
	According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0015. The time required to complete this information collection is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
	The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).
	To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

---

Sheet 4: Instructions

		INSTRUCTIONS
Section I PILOT INFORMATION (to be filled out by pilot seeking approval)
1 - 24			Self explanatory
25			Helicopter PIC hours in each Weight Class
26 - 32			Helicopter PIC hours in each category (round to the nearest hour)
33 - 37			Column “a”
				List only aircraft operated by employer designated in block 6
			Column “b”
				Do you hold an FAA Type Rating in the listed column “a” aircraft; check Yes or NO
			Column “c” (completion of all 3 categories required)
				PIC hours only for each listed column “a” aircraft
38			List current Part 135 approvals (use block 40 if additional space is needed)
39 - 42			Self explanatory
Section II APPROVALS (to be filled out by pilot inspector only)
1 a - u			Check or initial each Special Use Mission the pilot is qualified to perform. Items d, e, f, g, j, o and p require the agency, month and year the last flight evaluation was administered in that specific Special Use Mission (i.e. “DF 05/07” or “DA 05/07")
2			Check or initial whether a flight evaluation was administered with this approval
3 - 7			Self explanatory
8 - 12			Use to add additional aircraft after initial annual approval
13			Self explanatory
Section III HELICOPTER PILOT EVALUATION / QUALIFICATION CHECK
1 - 3			Self explanatory (to be filled out by pilot inspector only)
4			Make and Model of aircraft flight evaluation is conducted in (to be filled out by pilot inspector only)
5			Make and Model of all aircraft oral evaluation is conducted for (to be filled out by pilot inspector only)
6 - 8			Self explanatory (to be filled out by pilot inspector only)
9 - 10			Self explanatory (to be completed prior to flight by pilot to be evaluated)
Sections IV EQUIPMENT EXAM (to be filled out by pilot inspector only)
1 - 7			Cross out all blocks not evaluated; for those that are evaluated enter a “D’ for Demonstrated Ability, “K” for Knowledge or “U for Unsatisfactory
Sections V PERFORMANCE PLANNING AND PREFLIGHT (to be filled out by pilot inspector only)
1 - 6			Cross out all blocks not evaluated; for those that are evaluated enter a “D’ for Demonstrated Ability, “K” for Knowledge or “U for Unsatisfactory
Sections VI FLIGHT EVALUATION (to be filled out by pilot inspector only)
1 - 12			Cross out all blocks not evaluated; for those that are evaluated enter a “D’ for Demonstrated Ability, “K” for Knowledge or “U for Unsatisfactory
10 d, e, h			Check appropriate block
Section VII REMARKS, LIMITATIONS & APPROVALS (to be filled out by pilot inspector only)
1			Record approvals by aircraft make and model, applicable limitations, or remarks detailing reason(s) for disapproval
2			Initial block indicating final status of this evaluation
3			Expiration date of any agency pilot privileges granted
4			Self explanatory