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Chief Pilot / Supervisor Report

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Date of Report Request:

Name of Individual Being Monitored:

Date of Birth of Individual Being Monitored:

Employee ID (if applicable):

Please address the following:

Airman Performance and Competence	No Concerns Concerns
Crew Interaction	No Concerns Concerns
Mood	No Concerns Concerns
Presence of any other concerns, such as excessive sick leave or missing monitoring meetings	No Concerns Concerns

Further comments are appreciated to assist with oversight and monitoring by IMS and Psychiatrist:
(Consider asking questions such as: How has your life or program improved over the past 6 months?)

I agree to notify the IMS of any changes.

Today's Date:

Position or Job Title:

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Your legal name

Your email address

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Timestamp

Audit

March 4, 2022 1:53 pm MDT

Chief Pilot / Supervisor Report Uploaded by Caitlin Bruton - cbruton@aviationmedicine.com IP 69.129.92.41

March 17, 2022 12:51 pm MDT

IMS Records - imsrecords@aviationmedicine.com added by Caitlin Bruton - cbruton@aviationmedicine.com as a CC'd Recipient Ip: 69.129.92.41

March 17, 2022 12:54 pm MDT

IMS Records - imsrecords@aviationmedicine.com added by Caitlin Bruton - cbruton@aviationmedicine.com as a CC'd Recipient Ip: 69.129.92.41

April 13, 2022 2:01 pm MDT

IMS Records - imsrecords@aviationmedicine.com added by Caitlin Bruton - cbruton@aviationmedicine.com as a CC'd Recipient Ip: 69.129.92.41