1

Reporter and Date

2

Project and Equipment

3

Incident Classification

4

What Happened

5

Aircraft Status and Immediate Response

6

Notifications

FAA Part 107.9: If this incident involved a serious injury, loss of consciousness, or property damage exceeding $500, an FAA report may be required within 10 days. The DPA will make this determination during review — do not delay submitting this form pending that assessment.