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Aviation Safety Reporting Form

Instructions:

When completing this form, please provide as much information as possible.
Additionally, this form may be submitted anonymously.

Date of Incident

Time of Incident

Location of Incident

Airport Identifier (ex. LEX)

Please describe the location of the incident. Provide landmarks, distances, etc. if able.

Aircraft(s) Involved

Other:

Personnel Involved

Flight Student/Solo

Flight Instructor/Dual

Maintenance Personnel

FBO Line Staff

General Aviation/Other

Faculty/Staff

Phase of Flight

Text Description of Incident

Risk Actions (Select all that apply)

Conflict with aircraft in flight or on the ground

Conflict with personnel on the ground

Potential problem with a procedure

Possible training deficiency

Incorrect procedural occurrence

One time dangerous event

Unsafe operation of aircraft in flight or on ground

Issue with aircraft

Ticket Number: (To be assigned post-submission)

Upload Incident Photos or Documentation

Would you like to remain anonymous? (You can not be contacted about the results of this report if you are anonymous.)

Yes

Reporter Information (Optional)

First Name

Last Name

EKU ID

Email Address

Phone

Would you like to be contacted about the results of this report?

Yes

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