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HIMS Advanced-Airman Update

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Name:

Date of Birth:

Employee ID (if applicable):

Sobriety Date:

Number of peer support group meetings (AA, NA, etc) attended per week:

Last IMS Visit:

Initial Special Issuance Date:

Describe how you are maintaining abstinence based recovery:

I attest to full compliance with my current FAA special issuance requirements. I maintain abstinence from mind and mood altering substances and will do so for the duration of my flying career.

Today's Date:

Position or Job Title:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

March 4, 2022 1:49 pm MDT

HIMS Advanced-Airman Update Uploaded by Caitlin Bruton - cbruton@aviationmedicine.com IP 185.153.178.147

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

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