2120-0707 FAA Aerospace Medical Certification Services Pilot Satis

OMB Control Number 2120-XXXX

Exp. XX/XX/XXXX

2011 FAA Aerospace Medical Certification Services Pilot Satisfaction Survey

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PURPOSE: This questionnaire is being administered to a sample of US airmen from varying category and class ratings who have recently sought medical certification from an Aviation Medical Examiner (AME). You have been selected to serve as a representative of your category and class rating, so it is important that you complete and return this survey to the Federal Aviation Administration (FAA). The goal of this effort is to evaluate the quality of aerospace medical certification services and identify areas of concern so that the FAA may improve its services to airmen.

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Paperwork Reduction Act Statement: Submission of this form is voluntary. The public reporting burden for this collection of information is estimated at 15 minutes 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. Note: 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 control number for this collection is 2120-XXXX. 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, AES-200.

N2	AME SERVICES: Read each statement carefully and indicate your selection by marking the box that corresponds to the response that best describes your most recent experience in seeking your medical certificate.

1.	For which medical certificate did you most recently apply? (Required)
		Class I
		Class II
		Class III
		Did not apply for a medical certificate (Please stop here and return survey in enclosed envelope)

2.	How many months has it been since you applied for your most recent medical certificate?
		0-3 months		4-6 months		7-9 months		10-12 months		13 months or more

3.	How many miles did you have to travel for your most recent medical certificate exam?
		0-24 miles		25-50 miles		51-75 miles		76-100 miles		101 miles or more (Please explain)
	If 101 miles or more, please explain.
	______________________________________________________________________________________

4.	How many AMEs did you approach for your most recent medical certificate exam?
		1		2		3		4		5 or more

5.	Why did you select the AME who conducted your most recent medical certificate exam? (Mark all that apply)
		Referred by instructor		Quick certification decisions
		Referred by pilot		Low cost
		Referred by doctor		Conveniently located
		Performed previous exam(s)		Other (Please explain)

	If Other, please explain.
	____________________________________________________________________________________

6.	When scheduling your most recent medical certificate exam with the AME, did the office staff advise you to bring your medical history with you to the exam?
		Yes		No		Don't remember

7.	Did you submit your most recent medical history on-line using Form 8500-8 through MedXPress (OMB Control No. 2120-0034)?
		Yes (Skip to item 9)		No		Don't remember (Skip to item 12)

8.	If you did NOT submit your medical history on-line using Form 8500-8 through MedXPress (OMB Control No. 2120-0034), please indicate why. (Mark all that apply, then skip to item 12)
		I didn't know about MedXPress		No high-speed Internet service
		AME didn't use MedXPress		Didn't understand browser requirements for MedXPress
		Didn't trust Internet security		Other (Please explain)

	If Other, please explain.
	___________________________________________________________________________________

9.	During your most recent application for a medical certificate, how satisfied were you with the overall performance of MedXPress (OMB Control No. 2120-0034)?
		Very dissatisfied		Dissatisfied		Neither		Satisfied		Very satisfied

10.	Did the AME's office remind you to bring your MedXPress (OMB Control No. 2120-0034) confirmation number to your most recent medical certificate exam?
		Yes		No		Don't remember

11.	During your most recent application for a medical certificate, was the AME able to access your MedXPress Form 8500-8 (OMB Control No. 2120-0034) using the confirmation number you had received?
		Yes		No		Did not bring confirmation number

12.	Who reviewed your medical history with you during your most recent application for a medical certificate? (Mark all that apply)
		AME		Physician's Assistant		Other office personnel
		Physician (non-AME)		Nurse		No one reviewed my medical history with me

13.	Who performed the physical exam during your most recent application for a medical certificate? (Mark all that apply)
		AME		Physician's Assistant		Other office personnel
		Physician (non-AME)		Nurse		No one performed a physical exam

14.	Was your most recent medical certificate issued on the same day as your examination?
		Yes (Skip to item 19)		No

15.	How long did the AME tell you it would take to receive your most recent medical certificate?
		2-10 days		11-30 days		31-90 days		91 days or more		Didn't say

16.	How long did it actually take to receive your most recent medical certificate?
		2-10 days		31-90 days		Still deferred
		11-30 days		91 days or more		Denied

17.	Which of the following best describes what happened to delay the issuance of your most recent medical certificate?
		The AME had to obtain additional information before issuing my certificate (i.e., a report from another physician). (Skip to item 19)
		The AME had to refer my application to the Regional Flight Surgeon (RFS) or to the Aerospace Medical Certification Division (AMCD) in Oklahoma City for review.

18.		If you indicated that the AME had to refer your most recent medical certificate application to the RFS or the AMCD in Oklahoma City for review, which of the following best describes what happened?
			No additional information was requested from me before my certificate was issued.
			I had to supply additional information and then my certificate was issued.
			My most recent application is still under review.
			I was denied a certificate for my most recent application.
	AME SERVICE QUALITY: Read each statement carefully and indicate your selection by marking the box that corresponds to the response that best describes your most recent experience in seeking your medical certificate.

During your most recent application for a medical certificate, to what extent did your AME...

		Not at all	Limited extent	Moderate extent	Considerable extent	Great extent
19.	perform a thorough medical examination?					
20.	provide a professional setting for the examination, including cleanliness and appearance?					
21.	charge appropriately for his/her services?					
22.	clearly explain your responsibilities in the medical certification process?					
23.	provide you with all the information you requested?					
24.	provide information you requested in a timely manner?					
25.	provide you with accurate information?					
26.	treat you with courtesy and respect?					

	During your most recent application for a medical certificate, did your AME...
			Yes	No
27.		examine your eyes/ears with a medical device?		
28.		have you remove or undo articles of clothing for the exam?		
29.		listen to your heart/lungs?		

OVERALL IMPRESSION OF YOUR MOST RECENT AME EXPERIENCE: Read each statement carefully and indicate your selection by marking the box that corresponds to the response that best describes your most recent experience in seeking your medical certificate.

30.	How satisfied were you overall with your most recent medical certificate exam?
		Very dissatisfied		Dissatisfied		Neither		Satisfied		Very satisfied

31.	How satisfied were you overall with the quality of service provided by your AME during your most recent experience?
		Very dissatisfied		Dissatisfied		Neither		Satisfied		Very satisfied

32.

Based on your most recent experience with your AME, to what extent does the FAA medical certification process ensure the safety of the National Airspace System?



Not at all



Limited extent



Moderate extent



Considerable extent



Great extent



Don't know

FAA SERVICE QUALITY: Read each statement carefully and indicate your selection by marking the box that corresponds to the response that best describes your most recent experience in seeking your medical certificate.

33.	During your most recent application for a medical certificate, what type of contact did you have with FAA medical representatives? (Mark all that apply)
		Phone		E-mail		Postal mail		None (Skip to item 45)

34.	During your most recent application for a medical certificate, with which FAA medical representative(s) did you have contact? (Mark all that apply)
		FAA Regional Medical Division
		Aerospace Medical Certification Division (AMCD) in Oklahoma City
		Washington, DC Headquarters (Office of Aerospace Medicine)

35.		How long did the FAA medical representative(s) tell you it would take to receive your most recent medical certificate? (Mark all that apply)
			2-10 days		11-30 days		31-90 days		91 days or more		Didn't say
	During your most recent application for a medical certificate, to what extent did FAA medical representatives you had contact with...

		Not at all		Limited extent		Moderate extent		Considerable extent		Great extent
36.	clearly explain your responsibilities in the medical certification process?									
37.	provide you with all the information you requested?									
38.	provide information you requested in a timely manner?									
39.	provide you with accurate information?									
40.	treat you with courtesy and respect?									

41.	How satisfied were you overall with your most recent experience with the FAA medical representative(s)?
		Very dissatisfied		Dissatisfied		Neither		Satisfied		Very satisfied

42.

Based on your most recent experience with the FAA medical representative(s), to what extent does the FAA medical certification process ensure the safety of the National Airspace System?



Not at all



Limited extent



Moderate extent



Considerable extent



Great extent



Don't know

BACKGROUND INFORMATION: Read each statement carefully and indicate your selection by marking the box that corresponds to the response that best describes your background.

43.	What pilot certificates do you currently hold? (Mark all that apply)
		Student pilot		Recreational pilot		Private pilot		Commercial pilot		Airline Transport pilot

44.	What ratings do you hold? (Mark all that apply)
		Instrumental Flight Rules (IFR)		Certified Flight Instructor (CFI)		Do not hold any ratings

45.	How are you currently employed?
		Full-time pilot		Part-time pilot		Not employed as pilot (Skip to item 49)

46.	Are you employed as a pilot for a certificated operator conducting flights under …? (Mark all that apply).
			Part 91 (Corporate)
			Part 121 (Flag, domestic, supplemental operations)
			Part 125 (Aircraft with 20 or more seats and cargo payload of 6,000 pounds or more when common carriage is not involved)
			Part 129 (Foreign air carrier & foreign operator of US-registered aircraft used in common carriage)
			Part 133 (Rotorcraft external loads)
			Part 135 (Commuter/On-demand operations)
			Part 137 (Agricultural operations)
			Part 141 (Pilot schools)
			Other (Please explain)

	If Other, please explain.
	___________________________________________________

47.	Which region handles your medical certification? (Required)
		Alaskan Region [Alaska]
		Central Region [Iowa, Kansas, Missouri, Nebraska]
		Eastern Region [Delaware, Maryland, New Jersey, New York, Pennsylvania, Virginia, West Virginia]
		Great Lakes Region [Illinois, Indiana, Michigan, Minnesota, North Dakota, Ohio, South Dakota, Wisconsin]
		New England Region [Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont]
		Northwest Mountain Region [Colorado, Idaho, Montana, Oregon, Utah, Washington, Wyoming]
		Southern Region [Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee]
		Southwest Region [Arkansas, Louisiana, New Mexico, Oklahoma, Texas]
		Western-Pacific Region [Arizona, California, Hawaii, Nevada]

48.	What type of comments do you have for improving Aerospace Medical Certification Services (AMCS)? (Mark all that apply and provide comment(s) in the box provided).
		No comment		Compliment		Complaint		Recommendation

Please provide comments or helpful suggestions. Identifying information, such as names, will be removed. Please note that comments are subject to the Freedom of Information Act (FOIA).

Thank you for taking the time to help us improve our services!

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