Interagency SAFECOM Entry Form www.SAFECOM.gov

Safety Communiqué Form

This form is used to report any condition, observance, act, maintenance problem, or circumstance which has
the potential to cause an aviation-related mishap. Submitting a SAFECOM is not a substitute for on-the-spot
correction(s). Note:

denotes a required input field.

REPORTED BY (optional)

Name:
E-Mail:
Phone:
Cell Phone:
Pager:
Organization:
	:Org-Other
Date Submitted:	2/13/2013

EVENT

Date:

mm / dd / yyyy

Local Time:

24 hour clock

Injuries:

Damage:

Operational Control:
Agency:
Region:
Unit:

Location:	Airport, City, Lat/Long, or Fire Name
State:

MISSION

Type:		Other:
Procurement:		Other:

Persons Onboard:

Special Use:

Hazardous Materials:

Departure Point:

Destination:

AIRCRAFT

Type:

Tail #:

Manufacturer:

Model:

Owner/Operator:

Pilot:

Manager:

NARRATIVE (A brief explanation of the event - 8000 character max)

CORRECTIVE ACTION (What was done to correct the problem - 8000 character max)

REVIEW INSTRUCTIONS

1) To proceed with your SAFECOM submission, select the CONTINUE button to the right. From the next screen you will be able to review your SAFECOM, print a copy for your records and SUBMIT. You will also be able to make changes after reviewing if necessary.
2) From the next screen you can attach image files (JPG and GIF Only) and PDFs to your SAFECOM. You will be able to review your SAFECOM, print a copy for your records and SUBMIT it. You will also have the option to make changes after reviewing if necessary prior to submission.

3) If you'd like to clear the form and start over, select the CLEAR FORM button to the right.

Click here to download the a PDF version of SAFECOM (Form AMD-34 or FS 5700-14).
If you do not have Adobe Acrobat reader currently installed, you will need to download the FREE reader.

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