Please fill out the form with as much information as you can. When done, press the "submit" button at the bottom of the form.

Reporter:

Name:
E-mail Address:
Address:
City:
State: Zip Code:
Phone:

Note: This information is kept confidential. It is only used, in case we want to contact you for clarifications on this form.

A. General Information:

1. Type: 2. Injuries: 3. Damage:

4. Date Of Occurence: (mm/dd/yyyy) 5. Time: (local)

6. Location (city or town, state, and site name):

7. Brief Description:

B. Operator:

1. Name And Address:

2. Registered With USUA?: 3. Age: 4. Sex: 5. Weight:

6. Operator's Ultralight Experience:

Total hours of instruction: Hours in make/model:
Hours flown last 6 months: Time since last flight:
Total UL hours: Months of UL experience:
Other:

7. FAA Rating(s)?:

None ATP Student BGI or AGI Private
Military Commercial Rotary CFI Balloon
Other Type Not Listed Above:

Total Hours:

8. Condition: Other:

C. Vehicle:

1. Make And Model:

2. Serial Number: 3. Engine:

4. Registered With USUA?: 5. USUA Registration Number: (if applicable)

6. Modifications:

7. Hours On Vehicle: 8. Persons On Board:

9. Equipment:

ASI Parachute
Helmet Other:

10. Ownership: Other:

11. Storage: Other:

D. Location:

1. Area: Other:

2. Site/Terrain:

Yard Building Park Airport
FlightPark Field Forest Parking Lot
Street/Road Water Desert Coastal
Flat Hilly Mountains Other:

3. Airspace: Other:

4. Elevation: (MSL)

E. Flight History:

1. Source of Flight: Other:

2. Purpose Of Flight: Other:

3. Phase Of Flight: Other:

4. Length Of This Flight: (hh:mm)

5. Altitude: (above ground level)

F. Weather:

1. Sky Conditions:

2. Light:

3. Turbulence:

4. Visibility: (miles)

5. Temperature: (F)

6. Wind Velocity: (mph) Gusting to: (mph)

G. Additional Information:

1. Third Party Injuries:

2. Third Party Damage: Other:

3. Components Damaged:

4. Cause Factors:

Unknown: Ultralight Design:
Inadequate Instruction: Unauthorized Operations:
Unauthorized Modifications: Weather
Pilot Induced Oscillations: Structural:
Improper Power Management: Aerobatics:
Improper Use Of Controls: Power Lines:
Collision With Ground Object: Medically Impaired:
Buzzing/Flying Too Low: Inadequate Preflight:
Fuel Starvation: Control System Failure:
Fuel Exhaustion: Flying Under The Influence:
Inadequate Operating Site: Midair Collision:
Vortex Turbulence: Pilot Error:
Darkness: Engine Failure:
Foreign Object In Prop: Inadequate Maintenance:
Failure To Maintain Flight Speed: Manufacturer Defect:
Drive Train Failure:
Other:

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Thank you!