Incident Report Form
PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS THAT APPLY TO THIS EVENT OR SITUATION.
Basic Information
Campus Daytona
Date
mm dd yyyy
Time
( local, 24 hr)
hour minutes
Event Category (optional)
Role and Experience - Submitter
Name (all names are held in strict confidence)
last first
Role on this flight
Flying Time total  hrs
Role and Experience - Person #2 (if applicable)
Name
last first
Role on this flight
Flying Time total  hrs
Instructor
last first
Team Manager
last first
Flight Environment
Type of aircraft (make/model)
Aircraft call Sign
Location: distance and radial from airport, navaid, or other fix
Flight phase at time of occurrence
Day/Night reserved
Flight Plan
Purpose of flight reserved
Meteorological condition reserved
Airspace  reserved
Other weather

(Please check
all that apply)

rain fog
ice snow
turbulence thunderstorm
windshear other
Altitude   MSL     AGL
Ceiling feet Visibility  miles
ATC
Runway in use
Was an emergency declared?
Description of Event
Main
narrative
Self Reflection (optional)
 
What went wrong?
What went right?
What would you do different?
What did you learn?
Would you like feedback on this case? yes
NMAC (Near Mid Air Collision)/ATC Incident
Flight phase at time of occurrence
Location
Distance estimate vertical (ft) horizontal (ft)
Bearing relative to aircraft degrees
Pictorial view of other aircraft at first sighting
Evasive action?


What part did ADS-B/TIS play in avoiding
a midair collision?
General Outcome