FAA-8500-20 Medical Exemption Petition

INFORMATION FOR APPLICANT
U.S. Department
of Transportation
Federal Aviation
Administration

MEDICAL EXEMPTION PETITION (Operational Questionnaire)
Privacy Act Statement

Information requested on this form is solicited under the authority of Title 49 of the United States Code
(Transportation) sections 109(9), 40113(a), 44701-44703, and 44709 (1994) formerly codified in the Federal
Aviation Act of 1958, as amended, and Title 14 of the Code of Federal Regulations (CFR), Part 67, Medical

Standards and Certification. Submission of this information is mandatory and incomplete submission will result

in delay of consideration of or denial of application for an airman medical certificate.

The purpose of this information is to determine whether an applicant meets Federal Aviation Administration
medical requirements to hold an airman medical certificate for further consideration under 14 CFR 11.53 and
67.401. It is also used to depict airman population patterns and to update certification procedures and medical
standards. The information collected on this form becomes a part of the Privacy Act System of Records
DOT/FAA 847, General Air Transportation Records on individuals, and is provided the protection outlined in
the system's description as published in the Federal Register.

Paperwork Reduction Act Statement: Applicants not meeting the medical standards prescribed by

Part 67, but who desire to perform aviation activities, must submit FAA Form 8500-20, Medical Exemption
Petition (Operational Questionnaire), as part of the special issuance request. information obtained on this form
facilitates a fair and equitable ruling that may permit applicants to perform operational activities that are
commensurate with their medical condition and public safety. Submission of information is mandatory. The
purpose of this information is to determine whether an applicant meets FAA medical requirements to hold an
airman medical certificate for further consideration under Title 14 of the Code of Federal Regulations (CFR)
11.53 and 67.401. Any person who is denied a medical certificate by an aviation medical examiner may appeal
to the Federal Air Surgeon under 14 CFR 67.409, Denial of medical certificate. This information is also used to
depict airman population patterns and to update certification procedures and medical standards.

If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please
direct your comments to the FAA at the following address: Federal Aviation Administration; Aeromedical
Certification Division, AAM-300; P.O. Box 26080; Oklahoma City, OK 73126-9922. The public reporting burden
for collection of information is estimated to average 8 minutes per response The agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The paperwork burden associated with this form is currently approved under OMB
number 2120-0034. Comments concerning the accuracy of this burden and suggestions for reducing the burden
should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information
Collection Clearance Officer, ABA-20

ORM 8500-20 (9-97) Supersedes Previous Edition

Tear off this cover sheet before submitting this form

Form Approved OMB No. 2120-0034
01/31/2008

MEDICAL EXEMPTION PETITION
(Operational Questionnaire)
Name: (Last, First, Middle)

Pl#

Address: (No. Street, City, State, ZIP Code)

Date of Birth: (Month, Day, Year)

Check applicable item(s) in each category indicating how you plan to use the medical certificate for which you are applying. If additional space
is needed for explanation, use reverse side of this form.
1. TYPES OF AIRCRAFT
Single Engine

Multi-engine

Helicopter

Jet

Sea or Skiplane

Experimental

Special aircraft or equipment. Give details:

Other: Give details.
2. TYPES OF OPERATIONS
Acrobatics

Daylight Operations

Mountainous (

Aerial Application (cropdusting, etc.)

Night Operations

Remote (pipeline patrol, ranching)

Aerial Patrol (police, fire, border, etc.)

Instrument Flying

Self-employed, Private

feet elevation)

Air Taxi Operations

Supersonic Flight

Flying involving carrying passengers for compensation or hire

Altitudes above 8,000 feet

Travel Club

Flying involving carrying cargo for compensation or hire

Corporate or Business

Transoceanic,
Over Water

High Density Traffic, Metropolitan Areas

Other: Give details.
3. DUTIES
Pilot-in-Command

Second-in-Command

Flight Engineer

Proficiency

Instructor, Flight Training Check Pilot:

Line

Other: Give details.
4A. Maximum Daily Flight Time: (Circle AM or PM)

4B. Maximum Daily Duty Time: (Circle AM or PM)

A.M.
From:

P. M.

4C. Scheduling Irregular:

A. M.

From:

P.M.

To:

A.M.
P.M.

No

Yes

5. Will you be under any medical supervision in your flight operations other that provided by FAA
regulations? If YES, explain.

No

Yes

6. In carrying out your flight activities, will there be another qualified pilot In the cockpit on all flights? If YES,
explain.

No

Yes

7. In the event you are found not qualified for the class of medical certificate sought, would you accept a
lower class? If YES, explaln.

No

Yes

To:

A.M.
P.M.

FAA FORM 8500-20 (9-97) Supersedes Previous Edition