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:

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Signature Certificate
Document name: HIMS Advanced-Airman Update
lock iconUnique Document ID: f12e1e04665ae6ab3c307bfe5e4f7465b4fc23ba
Timestamp Audit
March 4, 2022 1:49 pm MDTHIMS Advanced-Airman Update Uploaded by Caitlin Bruton - cbruton@aviationmedicine.com IP 69.129.92.41
March 17, 2022 12:51 pm MDTIMS 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 MDTIMS Records - imsrecords@aviationmedicine.com added by Caitlin Bruton - cbruton@aviationmedicine.com as a CC'd Recipient Ip: 69.129.92.41