Form AC 70-2 (questionn AC 70-2 (questionn Laser Beam Exposure Questionnaire

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 2120-0698. Public reporting for this collection of information is estimated to be approximately 10 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. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110.

OMB Control Number 2120-0698

Exp. 11/30/2014

LASER BEAM EXPOSURE QUESTIONNAIRE

FAX TO WASHINGTON OPERATIONS CONTROL CENTER(WOCC) at (202) 267-5289 ATTN: DEN

PILOT NAME________________________________ PHONE NUMBER__________________

COMPANY __________________________________ FLIGHT NUMBER__________________

1. Date and time (UTC) ?__________________________________________________________________________

2. Position of event (lat/long and/or FRD)? ___________________________________________________________________________

3. Altitude? _____________________________________________________________________________________________________

4. What was the visibility?

5. What were the atmospheric conditions? (Circle those which apply) – Clear, overcast, rainy, foggy, hazy, sunny.

6. What was the color(s) of the light?

7. Did the color(s) change during the exposure?

8. Did you attempt an evasive maneuver?

If so, did the beam follow you as you tried to move away?

9. Can you estimate how far away the light source was from your location?

10. What was the position of the light relative to the aircraft? ______________________________________________________________

11. Was the source moving?

12. Was the light coming directly from its source or did it appear to be reflected off other surfaces?

13. Were there multiple sources of light?

14. How long was the exposure?

15. Did the light seem to track your path or was there incidental contact?

16. What tasks were you performing when the exposure occurred?

Did the light prevent or hamper you from doing those tasks, or was the light more of an annoyance?

17. What were the visual effects you experienced (after-image, blind spot, flash-blindness, glare*)?

18. Did you report the incident by radio to ATC?

Any other pertinant information: ___________________________________________________________________________________

_____________________________________________________________________________________________________

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This questionnaire may be filled out by the competent authority during interviews with aircrews exposed to unauthorized laser illumination. This information will be used to aid in subsequent investigation by ATC, law enforcement and other governmental agencies to safeguard the safety and efficiency of civil aviation operations in the NAS.

*Examples of common visual effects:

After-image. An image that remains in the visual field after an exposure to a bright light.

Blind spot. A temporary or permanent loss of vision of part of the visual field.

Flash-blindness. The inability to see (either temporarily or permanently) caused by bright light entering the eye and persisting after the illumination has ceased.

Glare. A temporary disruption in vision caused by the presence of a bright light (such as an oncoming car's headlights) within an individual's field of vision. Glare lasts only as long as the bright light is actually present within the individual's field of vision.