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Items marked with an asterisk (*) are mandatory items.

General Information:

* Report version:

* Reported by:

* Telephone: ex. (555)555-5555

Fax: ex. (555)555-5555

E-mail:

Organization:

Source IP: 75.22.20.141

Occurrence Information:

* Incident type:

* Location:

* Incident Date:

(yyyy-mm-dd)

* Incident Time:
ex. 18:12
(24 hour, local)

Aircraft/Vehicle Information:

Aircraft/Vehicle Number 1:

Identification:

Type/Model:

Registration:

Operator:

Aircraft/Vehicle Number 2:

Identification:

Type/Model:

Registration:

Owner/Operator:

Route:

Aircraft/Vehicle Number 1:

Departure:

En route stops:

Destination:

Aircraft/Vehicle Number 2:

Departure:

En route stops:

Destination:

Persons Involved:

Total: Killed: Injured:

Aircraft/Vehicle Number 1:

Total Crew: Crew Killed: Crew Injured:

Total Pax: Pax Killed: Pax Injured:

Total Other: Other Killed: Other Injured:

Aircraft/Vehicle Number 2:

Total Crew: Crew Killed: Crew Injured:

Total Pax: Pax Killed: Pax Injured:

Total Other: Other Killed: Other Injured:

* Summary Description (including operational impact): (4000 Character Maximum)