Report a Laser Incident

Paperwork Reduction Act Burden Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0698. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to FAA at:

800 Independence Ave. SW, Washington, D.C. 20591
Attn: Information Collection Clearance Officer, ASP-110
OMB Control Number: 2120-0698
Expiration Date: August 31, 2018

Pilot or crew member reporting
What seat in the cockpit were you occupying
How many pilots/crew members had laser light directly enter their eyes?
If multiple pilots/crew members had direct exposure to laser light in their eyes, each person exposed should fill out this laser incident report.
Flight and aircraft
Aircraft category
Operation type
Fixed radial distance (FRD) from navaid or airport — or latitude/longitude coordinates
Example: "The laser source relative to KDFW approach end of runway 35L was approximately 220 degrees radial and two miles." You can also provide estimated lat/long coordinates.
Primary flight direction
Phase(s) of flight
Effect on flight
Interference
Did the laser incident interfere with your pilot or crew member duties?
Flight path
Did the laser incident cause the pilot/crew member to change the aircraft flight path?
Laser incident
Tracking
Did the laser beam appear to deliberately track the aircraft?
Cockpit illumination
Did the laser beam enter through the windscreen and illuminate any part of the cockpit?
Eye exposure
Did the laser beam shine directly into one or both of your eyes?
Effect on your eye(s)
Effect on your eye(s)
Vision effects
Did you experience any adverse vision effects from the exposure?

Examples of common vision effects

Glare
A temporary disruption in vision caused by the presence of a bright light (such as an oncoming car's headlights) within an individual's field of vision. Glare lasts only as long as the bright light is actually present within the individuals field of vision.
Flash blindness
A temporary visual interference effect that persists after the source of the illumination has ceased, similar to a bright camera flash.
Afterimage
An image that remains in the visual field after an exposure to a bright light.
Blind spot
A temporary or permanent loss of vision of part of the visual field. Unlike an afterimage, a blind spot does not fade, or fades very slowly (taking many minutes, hours, or days to fade out).
Physical effects
Did you experience any adverse physical effects from the exposure?
Did you rub your eye(s) after the exposure?
Did you have an eye exam after the laser incident?
Eye exam results
What type of doctor performed the primary or most comprehensive examination of your eye(s)?
Laser incident reporting
Did you report the incident to Air Traffic Control (ATC)?
Did you report the laser incident to an FAA Flight Standards (AFS) field office?
Example of field office: FSDOCMOCHDO
Additional information
Did you have any prior knowledge or training on the hazards and effects of lasers aimed at a pilot/crew member?
ATC Facilities' use only
Domestic Incidents Network
Did you report the laser incident to the Domestic Incidents Network (DEN)?
Include the agency's phone number.
Was an arrest made?