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 10 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 the FAA at:
800 Independence Ave. SW, Washington, DC 20591
Attn: Information Collection Clearance Officer, ASP-110.
OMB Control Number: 2120-0698
Expiration Date: 8/31/2018
Name of pilot/crew member reporting
Flight number, call sign, and aircraft registration number
Aircraft Make and Model
Laser light color:
Select Beam Color
Location of aircraft during incident
Approximate altitude AGL
Please feel free to add any additional information or comments about your flight, the laser incident, reporting, and/or subsequent outcome:
Thank you for taking time to complete this short version of the FAA Laser Beam Exposure Questionnaire. You will receive an email at the address you provided above with details on how to complete the full version of the questionnaire.
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