Form FS-5700-20 Airplane Pilot Qualifications and Approval Record

FS-5700-20 (03/2008)

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

AIRPLANE PILOT QUALIFICATIONS AND APPROVAL RECORD (Reference FSH 5709.16)

► SECTION I – PILOT INFORMATION (Fill in the blanks) ◄

1. Name (Last, First, Middle Initial)

2. Date of Birth

3. Home Telephone No.

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

5. Employed by

6. Address

7. Telephone No.

8. Employed since

9. Previous Employer

10. Address

11. Telephone No.

12. Period Employed

13. Previous Employer

14. Address

15. Telephone No.

16. Period Employed

17. Medical Certificate Class __________________________ b. Date __________________________

18. Airman Certificate (Circle) a. Number _________________________________ b. ATP c. Com d. Instrument e. SEL f. MEL g. SES h. MES i. CFI j. Type Ratings _______________________________

19. Aircraft To Be flown Total PIC Hours (a) (b) 1. __________________ __________________ 2. __________________ __________________ 3. __________________ __________________

________________________________________________________

Flight Type

Hours

PART 135 FLIGHT CHECKS

Date

Make/Model A/C

VFR

IFR

IFR W/AP

20. Total Pilot Time (Airplane)

35.

21. Pilot-in-Command (PIC) Airplane

36.

22. Total X-Country

37.

23. Total Night

38.

24. Instrument: In Flight

Note: 135 Flight Checks Must Cover Type of Operations Required By Contract.

25. Instrument: Actual

39. Date of Previous Agency Card Approval a. AMD _________ b. USFS _________

40. Date of Last Agency Flight Check a. AMD _________ b. USFS _________

26. Instrument: Simulated

27. PIC Airplane: Last 12 Months

41. Aircraft Accidents/FAA Violations Filed Within Last 5 Years: ____________No _____________Yes (If yes, Attach Date and Explanation)

28. PIC Airplane: Last 60 Days

29. PIC “Low Level” Opns (-500 AGL)

42. Previous AMD or USFS Approval Denied, Suspended, or Revoked: _________No ________Yes (If yes, Attach Date and Explanation)

30. PIC “Mountainous Terrain”

31. PIC Aircraft over 12,500 # Gr. Wt.

43. PIC “Air Tactical” Operations: Number of Missions in the Last 24 Months: ______________

32. PIC Airtanker/Dispensing Operations

44. Airtanker Operations Only: a. Date Last PIC IFR Check in Type ___________ b. Date Last FAR 61.55 SIC Check _________________ c. No. of Takeoff/Landings Last 90 Days ________ d. No. of Night Takeoff/Landings Last 90 Days ________

33. PIC, Single Engine Airplane

Land

Sea

I certify that the information listed on this form is true and correct. In addition, I certify that I have read the statements on the back of this form covering information pursuant to Public Law 93-579 (Privacy Act of 1974) and any amendment thereto.

34. PIC, Multi-Engine Airplane

Land

Sea

45. Signature (Pilot)

46. Date

► SECTION II – For Inspectors Use Only (Initial appropriate Missions) ◄

1. Missions Approved For: (Inspector shall initial) a. ( ) Low Level g. ( ) Mountainous Terrain m. ( ) SEAT Pilot-Level _____ b. ( ) Resource Recon h. ( ) Category 4 Airstrip n. ( ) Infrared Operations c. ( ) Air Tactical i. ( ) Unprepared (Airstrip) Landings o. ( ) Point-To-Point d. ( ) Smokejumper PIC j. ( ) Airtanker PIC p. ( ) Other ____________ e. ( ) Smokejumper SIC k. ( ) Airtanker Initial Attack q. ( ) Other ____________ f. ( ) Paracargo l. ( ) Airtanker SIC r. ( ) Other ____________

2. SEL __________ 3. SES _________ 4. MEL __________ 5. MES ___________ 6. IFR, W/SIC __________ 7. IFR, Single Pilot __________ 8. Single Engine IFR _________

9. Type Aircraft Approved For:

10. Print Name (Inspector)

11. Signature (Inspector)

12. Agency

13. Date

14. Expiration Date

15. Aircraft/Contract Rental Agreement No(s).

16. Remarks

SECTION III – Pilot Evaluation/Qualification Check (To be filled out by Inspector)
1. Type of Evaluation (X appropriate box) Interim Initial Recurrent Post-Accident									2. Date
3. Name (last, First, Middle Initial)	4. Knowledge Make and Model							5. Competency Make and Model
6. Employed By	7. Location of Check								8. Flight Time
Insert one of the following letters below each Section (IV thru VI), if applicable D – Demonstrated Ability K – Knowledge U - Unsatisfactory
SECTION IV Equipment Exam – (Oral/Written)				7. Approach/Landing
1. Aircraft / Pilot Documents				a. Wind Evaluation
2. Weight and Balance (Down Loading)				b. Helispot Evaluation (H)
3. Fuel Requirements				c. Normal (Wheel / Stall)
4. Systems Operation				d. Crosswind/Slip Approach
5. Emergency Procedures				e. Short / Soft Field Landings (A)
6. Emergency / Survival Equipment				f. Rejected Landing/Go-Around
7. Operation/Safety Briefing				g. Winter / Ski Operations/Snow Landings
SECTION V – Preflight				h. STOL Operations (A)
1. Aircraft Documents				i. Pinnacle or Platform (H)
2. Manifest and Flight Plan				j. Confined Area (H)
3. Weight and Balance				k. Slope Landing (H)
4. Preflight Procedure				8. Emergency Procedures
5. Use of Check List				a. Engine Failure After Takeoff
SECTION VI – Flight Check				b. Maneuvering with Engine Out
1. Starting Procedure				c. V-Speeds (A)
2. Communication and Navigation Equipment Check				d. Approach and Landing, One Engine Out
3. Hover Taxi/Ground Taxi				e. System Emergencies
4. Run-up/Power Check				f. Autorotation / Forced Landings
5. Take-off Operations				g. Antitorque Failure (H)
a. Normal				h. Hydraulic Failure
b. Crosswind				9. Instrument Procedures
c. Maximum Performance				a. Equipment Check
d. Short/Soft (A)				b. ATC Procedures
e. Aborted				c. Navigation/Orientation
6. Air-Work Maneuvers				d. Holding
a. Smoke-Helipot Jumping / Rappeling				e. Approach – NDB, VOR, DME, LOC, ILS
b. App. To Stall, Slow Flight				f. Missed Approach / Circling Approach
c. Mountain Flying Technique				g. Speed, Heading Altitudes
d. Sling Operation/External Load				h. Automatic Pilot/Single Pilot (A)
e. Water / Retardant Dropping				i. Crew Coordination
f. Aerial Hunting				10. Water Operations
g. Offshore Navigation				a. Taxiing, Sailing, Docking
h. Horse and Game Hrdg / Cntg (H)				b. Step Taxi and Turns (A)
i. Night Operation				c. Glassy Water / Rough Water
j. Low-Level Operations				d. Takeoff and Landings
k. Fire Reconnaissance				11. Judgment
l. Steep Turns				12. Shutdown Checklist
m. En Route Procedures
13. Remarks / Limitations
14. Pilot Qualification Card Issued For:
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 during the check and that I may refuse to attempt any maneuver that, in my opinion, may be hazardous or unsafe.
15. Signature (pilot, Sigh Prior to Flight)							16. Type of Flight Check Passed __________ IFR __________ VFR
17. (X appropriate answer) _______Approved ______ Disapproved (See Remarks)			18. Expiration Date(s)			19. Signature (Inspector)

INSTRUCTIONS FOR AIRPLANE PILOT QUALIFICATIONS AND APPROVAL RECORD

Note: Print legibly in ink.

SECTION I – Pilot Information (to completed by applicant pilot)

Blocks 1 through 4 – Self-explanatory

Block 5 – Enter Current Employer

Blocks 6 through 8 – Self-explanatory

Blocks 9 and 13 – Include employers for whom worked, whose flight environment qualifies pilot for the type of flying to be contracted.

Block 10 through 12 – Self-explanatory.

Block 14 through 16 – Self-explanatory.

Block 17 – If medical certificate expires during the contract period, prepare and send a copy of the new one to the inspector pilot.

Block 18 – Self-explanatory.

Block 19 – Enter contracted aircraft and total PIC hours in that make/model of aircraft.

Blocks 20 through 29 – Self-explanatory

Block 30 – Mountainous Terrain Flight-Flight conducted above terrain referenced in 14 CFR 95.11. In addition, mountainous terrain flight must be at or below 2500 feet AGL. The pilot must be able to verify flight meeting the requirements outlined in this definition.

Blocks 31 through 34 – Self-explanatory

Blocks 35 through 38 – Under the VFR, IFR, and IFR W/AP columns check (√) each that apply to the FAA Form 8410-3 for that check ride.

Blocks 39, 40, and 42 – AMD (Aviation Management Directorate) formerly OAS (Office of Aircraft Services), Department of Interior and USFS (United States Forest Service), Department of Agriculture

Block 43 through 46 – Self-explanatory

Section II - Self-explanatory.

Section III

Blocks 1 through 3 are self-explanatory.

Block 4 - Knowledge of Make and Model. At times an oral statement may be given on one make and model, with a competency flight check in a different make and model. For this reason, each item must be acknowledged.

Blocks 5 through 8 - Self-explanatory.

Section IV, Equipment Exam (Oral / Written).

Delete the exam not given by blocking out with pen or pencil the inappropriate one.

1. Applicable items shall have either D – Demonstrated Ability, K – Knowledge, U – Unsatisfactory, to indicate the item has been reviewed.

2. Items that do not apply: Draw line to indicate not applicable.

3. Describe items that pertain to either helicopter or fixed wing, such as hover taxi / ground taxi; mark out any inapplicable items

Section V - Self-explanatory.

Section VI

Blocks 1 through 12 - Self-explanatory

Block 13 - Remarks / Limitations. Document comments for future reference, enter restrictions imposed on pilot, include reference information regarding follow-up letter (which should list restrictions).

Block 14 - Pilot Qualification Card Issued. Indicate OIC, SIC, MEL, SEL, SES, MES, helicopter or fixed wing, etc.

Block 15 – Pilot’s Signature and Type of Flight Check Passed

Pilot’s Signature. Pilot-in-command signs as receiving flight check prior to commencement of said flight check. The inspector-pilot will act as pilot-in-command only when prior arrangements made with applicant. The inspector’s signature is mandatory for completion of the check ride.

Type of Flight Check Passed. If the check is IFR, enter expiration date for IFR and for VFR, if applicable. If the flight check was for VFR only, enter expiration date in VFR space, ONLY.

Block 17 - Approved / Disapproved (mark one – required)

Blocks 18 and 19 - self-explanatory.

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.

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 available to Federal employees for the following uses:

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 violationo r potential violation of a statute, regulation, whether civil, criminal, or regulatory in nature, to the appropriate agency or agenices, 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.