Airlift Northwest

Safety Concern Form

Name: (optional)
Email: (optional)
Tracking ID: Required (What's this?)
Please check all that apply:
	This concern requires Safety Committee action
	This concern is being reported for educational purposes
	This concern is a question for discussion by the Safety Committee
	This concern is a suggestion for the Safety Committee
Date of event:
Time of day:
	AAOC was notified
What type of equipment was involved?
	Rotary Wing
	Fixed Wing
	Ground
Was weather a factor? Please explain.
Who was involved?
Please describe the event/concern in as much detail as possible.
Do you have a resolution you would like to recommend to the Safety Committee? Please explain.

This form is part of a confidential Quality Improvement Plan and as such is not subject to review or disclosure.