Form 2170-0761

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Overview

INSTRUCTIONS
Pg1 GENERAL + BASE LOCATIONS
Pg2 BASE LOCATIONS (optional)
Pg 3 BASE LOCATIONS (optional)
Pg 4 BASE LOCATIONS (optional)
Pg 5 BASE LOCATIONS (optional
Pg 6 BASE LOCATIONS (optional)
Pg7 ACCIDENT SUMMARY
Sheet1

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Sheet 1: INSTRUCTIONS

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

INSTRUCTIONS

Paperwork Reduction Act 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 2120-0756.  Public reporting for this collection of information is estimated to be approximately 6-16 hours 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 mandatory according to Public Law 112-95.  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.

This Data Collection Worksheet is the method authorized by the FAA Administrator for collection of Helicopter Air Ambulance Operations Flight Activity Data. Each Helicopter Air Ambulance Operator authorized by Operations Specification paragraph A021 must submit a report regarding their flight operations as directed below. This collection effort is mandated by Congress via Section 306 of the FAA Modernization and Reform Act of 2012.

This is a multi-page Micorsoft Exel 2003 .xls workbook, compatible with most installed Excel systems. The DETAILED INSTRUCTIONS, BY TOPIC below will explain how to properly complete this form. Make entries on the "REPORT" and "ACCIDENT DESCRIPTION" tabs of this template. Select from the tabs appearing near the bottom margin of this page to access those worksheets. Return to this page by selecting the "INSTRUCTIONS" tab.

The following file naming convention MUST be observed, submittals that are not identified in the following manner may not be accepted. The file name shall start with the calendar year of the reporting period, followed by the company designator, and end with "HAA". For example: a company with designator ABCD, reporting for calendar year (CY) 2019 would name their submittal file: "CY2015ABCDHAA.XLS". Make submittals via e-mail attachment and send your email to: <[email protected]>.

SECTION

DETAILED INSTRUCTIONS, BY SECTION

REPORTING PERIOD

Enter the reporting period as follows: Enter first date of reporting period, inclusive, in BEGINS cell. Enter last date of reporting period, inclusive, in ENDS cell. Normally, this will be 1/1/XXXX to 12/31/XXXX. If, however, the certificate holder was issued OpSpec A021 during the mid-year during the reporting period, the date A021 was issued should be entered in the BEGINS block. Likewise, if HAA operations ceased during the reporting year, enter the date those operations ceased in the ENDS cell

COMPANY IDENTITY

Enter Operator Name in NAME cell, enter FAA designator code (first 4 characters of the Air Carrier Certificate number) in DESIGNATOR cell.

TOTAL HAA HOURS FLOWN

Enter the total number of hours flown in HAA operations. Do not include flights for public relations events, maintenance, training, etc.

IFR HOURS FLOWN

Enter the total number of IFR hours flown in HAA operations. This includes IFR flights to pick-up patients/donor organs or tissue, flights to transport patients, and repositioning flights after patient/donor drop-off.

PATIENTS TRANSPORTED

Enter the number of patients transported during HAA operations.

HAA HOURS FLOWN AT NIGHT

Enter the total number of HAA hours flown at night.

TRANSPORT REQUESTS-

Enter the number of requests, either accepted or declined, in the appropriate category.

NUMBER OF ACCIDENTS-

Enter the total number, if any, the certificate holder suffered during the reporting period. Details of the accident(s) are to be entered on page 7 of the Report.

THE NUMBER OF TIMES ...

Enter the number of times, if any, in which a helicopter was not directly dispatched and arrived to transport patients but was not utilized for patient transport.

THE NUMBER OF HELICOPTERS

Enter the total number of helicopters used throughout the reporting period. Include all helicopters that were available for HAA operations even if no HAA operations were conducted during the reporting period.

BASE LOCATIONS-

Use the space on page 1 to list each base by FACILITY identifier if available, or Base name, and CITY, and STATE. If additional space is needed, use the optional pages, beginning on page 3 to continue listing bases.

ADDITIONAL ACCIDENT INFORMATION

List all accidents suffered during HAA operations for the reporting period on Page 7. In the BRIEF DESCRIPTION SECTION, Describe the circumstances leading to the accident. Include the approximate time of day, adverse weather, terrain or obstructions, apparent mechanical failures, pilot flight and time on duty since reporting that day, whether or not NVIS was in use, number of persons on board, whether or not a patient was on board, and any other pertinent information. If no accidents were suffered during the reporting period, enter "NONE" in the first BRIEF DESCRIPTION SECTION.

Unless otherwise specified by your Principal Inspector, your reporting period will be the calendar year beginning January 1st and ending December 31st of the same year. Submit your report within the 30 day period following the end of the reporting period.

The following file naming convention MUST be observed, submittals that are not identified in the following manner may not be accepted. The file name shall start with the calendar year of the reporting period, followed by the company designator, and end with "HAA". For example: a company with designator ABCD1234, reporting for calendar year (CY) 2015 would name their submittal file: "CY2019ABCD1234HAA.XLS". Make submittals via e-mail attachment and send your email to:

[email protected].

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Sheet 2: Pg1 GENERAL + BASE LOCATIONS

22	50	150		73	73	30	50	150	73	73	30	50	150	73	73	22
				HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
					SUBMIT TO:		[email protected]							OMB CONTROL #
														EXPIRATION DATE:
	REPORTING PERIOD						Total number of HAA transport requests either accepted or declined, as broken down by type of HAA flight conducted. TRANSPORT REQUESTS					Total number of incidents when the helicopter was assigned to and flew to a destination, but no patient was transported. THE NUMBER OF TIMES
	Date reporting period begins- MM/DD/YYYY BEGINS	12/21/2019	Date reporting period ends- MM/DD/YYYY ENDS	12/31/2019					ACCEPTED	DECLINED		if any, in which a helicopter was not directly dispatched and arrived to transport patients but was not utilized for patient transport.
								SCENE RESPONSE
	COMPANY IDENTITY							INTER-FACILITY TRANSFER
	NAME							ORGAN TRANSFER
	DESIGNATOR
							Total number of accidents occurring within the reporting period and involving a HAA capable helicopter during an HAA flight. NUMBER OF ACCIDENTS					THE NUMBER OF HELICOPTERS
	Total number of hours in HAA Service flights conducted by this Operator. TOTAL HAA HOURS FLOWN						For each accident, complete the accident summary information listed on page 7 of this report. Include additional pages if needed.					the certificate holder used during the reporting period to provide helicopter air ambulance services
	TOTAL number of hours flown by all HAA helicopters while on an HAA flight and on an IFR flight plan and clearance. IFR HOURS FLOWN
				Total number of patients transported on HAA flights conducted by this Operator. PATIENTS TRANSPORTED
	HAA HOURS FLOWN AT NIGHT
	BASE LOCATIONS OF HELICOPTERS
		CITY		STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	1						51					101
	2						52					102
	3						53					103
	4						54					104
	5						55					105
	6						56					106
	7						57					107
	8						58					108
	9						59					109
	10						60					110
	11						61					111
	12						62					112
	13						63					113
	14						64					114
	15						65					115
	16						66					116
	17						67					117
	18						68					118
	19						69					119
	20						70					120
	21						71					121
	22						72					122
	23						73					123
	24						74					124
	25						75					125
	26						76					126
	27						77					127
	28						78					128
	29						79					129
	30						80					130
	31						81					131
	32						82					132
	33						83					133
	34						84					134
	35						85					135
	36						86					136
	37						87					137
	38						88					138
	39						89					139
	40						90					140
	41						91					141
	42						92					142
	43						93					143
	44						94					144
	45						95					145
	46						96					146
	47						97					147
	48						98					148
	49						99					149
	50						100					150

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Sheet 3: Pg2 BASE LOCATIONS (optional)

22	50	150	73	73	30	50	150	73	73	30	50	150	73	73	22
			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	6/30/2020
						OPERATOR					DESIGNATOR
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	151					211					271
	152					212					272
	153					213					273
	154					214					274
	155					215					275
	156					216					276
	157					217					277
	158					218					278
	159					219					279
	160					220					280
	161					221					281
	162					222					282
	163					223					283
	164					224					284
	165					225					285
	166					226					286
	167					227					287
	168					228					288
	169					229					289
	170					230					290
	171					231					291
	172					232					292
	173					233					293
	174					234					294
	175					235					295
	176					236					296
	177					237					297
	178					238					298
	179					239					299
	180					240					300
	181					241					301
	182					242					302
	183					243					303
	184					244					304
	185					245					305
	186					246					306
	187					247					307
	188					248					308
	189					249					309
	190					250					310
	191					251					311
	192					252					312
	193					253					313
	194					254					314
	195					255					315
	196					256					316
	197					257					317
	198					258					318
	199					259					319
	200					260					320
	201					261					321
	202					262					322
	203					263					323
	204					264					324
	205					265					325
	206					266					326
	207					267					327
	208					268					328
	209					269					329
	210					270					330

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Sheet 4: Pg 3 BASE LOCATIONS (optional)

			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	6/30/2020
						OPERATOR					DESIGNATOR
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	331					391					p
	332					392					452
	333					393					453
	334					394					454
	335					395					455
	336					396					456
	337					397					457
	338					398					458
	339					399					459
	340					400					460
	341					401					461
	342					402					462
	343					403					463
	344					404					464
	345					405					465
	346					406					466
	347					407					467
	348					408					468
	349					409					469
	350					410					470
	351					411					471
	352					412					472
	353					413					473
	354					414					474
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	366					426					486
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	368					428					488
	369					429					489
	370					430					490
	371					431					491
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	373					433					493
	374					434					494
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	376					436					496
	377					437					497
	378					438					498
	379					439					499
	380					440					500
	381					441					501
	382					442					502
	383					443					503
	384					444					504
	385					445					505
	386					446					506
	387					447					507
	388					448					508
	389					449					509
	390					450					510

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Sheet 5: Pg 4 BASE LOCATIONS (optional)

			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	6/30/2020
						OPERATOR					DESIGNATOR
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	511					571					631
	512					572					632
	513					573					633
	514					574					634
	515					575					635
	516					576					636
	517					577					637
	518					578					638
	519					579					639
	520					580					640
	521					581					641
	522					582					642
	523					583					643
	524					584					644
	525					585					645
	526					586					646
	527					587					647
	528					588					648
	529					589					649
	530					590					650
	531					591					651
	532					592					652
	533					593					653
	534					594					654
	535					595					655
	536					596					656
	537					597					657
	538					598					658
	539					599					659
	540					600					660
	541					601					661
	542					602					662
	543					603					663
	544					604					664
	545					605					665
	546					606					666
	547					607					667
	548					608					668
	549					609					669
	550					610					670
	551					611					671
	552					612					672
	553					613					673
	554					614					674
	555					615					675
	556					616					676
	557					617					677
	558					618					678
	559					619					679
	560					620					680
	561					621					681
	562					622					682
	563					623					683
	564					624					684
	565					625					685
	566					626					686
	567					627					687
	568					628					688
	569					629					689
	570					630					690
22	50	150	73	73	30	50	150	73	73	30	50	150	73	73	22

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Sheet 6: Pg 5 BASE LOCATIONS (optional

			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	6/30/2020
						OPERATOR					DESIGNATOR
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	691					751					811
	692					752					812
	693					753					813
	694					754					814
	695					755					815
	696					756					816
	697					757					817
	698					758					818
	699					759					819
	700					760					820
	701					761					821
	702					762					822
	703					763					823
	704					764					824
	705					765					825
	706					766					826
	707					767					827
	708					768					828
	709					769					829
	710					770					830
	711					771					831
	712					772					832
	713					773					833
	714					774					834
	715					775					835
	716					776					836
	717					777					837
	718					778					838
	719					779					839
	720					780					840
	721					781					841
	722					782					842
	723					783					843
	724					784					844
	725					785					845
	726					786					846
	727					787					847
	728					788					848
	729					789					849
	730					790					850
	731					791					851
	732					792					852
	733					793					853
	734					794					854
	735					795					855
	736					796					856
	737					797					857
	738					798					858
	739					799					859
	740					800					860
	741					801					861
	742					802					862
	743					803					863
	744					804					864
	745					805					865
	746					806					866
	747					807					867
	748					808					868
	749					809					869
	750					810					870
22	50	150	73	73	30	50	150	73	73	30	50	150	73	73	22

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Sheet 7: Pg 6 BASE LOCATIONS (optional)

			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	6/30/2020
						OPERATOR					DESIGNATOR
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	871					931					991
	872					932					992
	873					933					993
	874					934					994
	875					935					995
	876					936					996
	877					937					997
	878					938					998
	879					939					999
	880					940					1000
	881					941					1001
	882					942					1002
	883					943					1003
	884					944					1004
	885					945					1005
	886					946					1006
	887					947					1007
	888					948					1008
	889					949					1009
	890					950					1010
	891					951					1011
	892					952					1012
	893					953					1013
	894					954					1014
	895					955					1015
	896					956					1016
	897					957					1017
	898					958					1018
	899					959					1019
	900					960					1020
	901					961					1021
	902					962					1022
	903					963					1023
	904					964					1024
	905					965					1025
	906					966					1026
	907					967					1027
	908					968					1028
	909					969					1029
	910					970					1030
	911					971					1031
	912					972					1032
	913					973					1033
	914					974					1034
	915					975					1035
	916					976					1036
	917					977					1037
	918					978					1038
	919					979					1039
	920					980					1040
	921					981					1041
	922					982					1042
	923					983					1043
	924					984					1044
	925					985					1045
	926					986					1046
	927					987					1047
	928					988					1048
	929					989					1049
	930					990					1050
22	50	150	73	73	30	50	150	73	73	30	50	150	73	73	22

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Sheet 8: Pg7 ACCIDENT SUMMARY

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

SUBMIT TO:

[email protected]

OMB CONTROL #

2120-0756

EXPIRATION DATE:

6/30/2020

OPERATOR

DESIGNATOR

ACCIDENT SUMMARY-

1

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

2

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

3

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

4

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

5

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

6

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

7

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

8

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

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Sheet 9: Sheet1

	HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT
	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
	151					211					271
	152					212					272
	153					213					273
	154					214					274
	155					215					275
	156					216					276
	157					217					277
	158					218					278
	159					219					279
	160					220					280
	161					221					281
	162					222					282
	163					223					283
	164					224					284
	165					225					285
	166					226					286
	167					227					287
	168					228					288
	169					229					289
	170					230					290
	171					231					291
	172					232					292
	173					233					293
	174					234					294
	175					235					295
	176					236					296
	177					237					297
	178					238					298
	179					239					299
	180					240					300
	181					241					301
	182					242					302
	183					243					303
	184					244					304
	185					245					305
	186					246					306
	187					247					307
	188					248					308
	189					249					309
	190					250					310
	191					251					311
	192					252					312
	193					253					313
	194					254					314
	195					255					315
	196					256					316
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	198					258					318
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	201					261					321
	202					262					322
	203					263					323
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	205					265					325
	206					266					326
	207					267					327
	208					268					328
	209					269					329
	210					270					330