Date of Occurence * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Please select one: * Accident Incident Malfunction An Accident shall be considered as any occurance during parachuting activities resulting in injury requiring medical attention. An Incident shall be considered as any occurance during parachuting activities which could have resulted in a situation leading to injury or fatality. A Malfunction shall be considered as any partial or complete failure of parachuting equipment which requires the initiation of emergency procedures. Location/Dropzone * Instructors Name (if applicable) Please select one: * Jumper Student Passenger Jumper / Student / Passenger Name * Age * Gender * Male Female CSPA # (if applicable) Weight * Height * # of jumps * Date of training (if applicable) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Date of Previous Jump (if applicable) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Time of Occurence * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Status * Tandem Student Static Line Student IAD Student PFF Self-supervision Exit method * Dynamic Poised Hanging Dive Main Activation Position * BOC POP Other If other, please describe Cutaway Performed? * Yes No Weather * Clear Scattered Broken Overcast Winds * Kts Aircraft Type * Exit Speed * Altitude * Harness/Container * Main Canopy * Size * Reserve Canopy * Size * Canopy Release Method * TAS SOS Other If other, please describe Experience on Equipment? * Yes No If yes, # of jumps RSL installed? * Yes No AAD * FXC 12000 Sentinel Cypres Astra Vigil Argus Mars Other None If other, please describe Accessories * Boots Sneakers Sandals Helmet Gloves Jumpsuit Goggles Hook knife Altimeter Audible Altimeter Radio Other If other, please describe Description of Accident/Incident/Malfunction * List the type of injury sustained, location, etc...as well as the events causing the A/I/M Written by (Full Name) * Signature * By checking here, you are consenting to use your electronic signature in lieu of an original signature on paper. Investigated by (Full Name) * Signature * By checking here, you are consenting to use your electronic signature in lieu of an original signature on paper. Recommendations * To be conducted by the DZ Safety Officer Recommendations by (Full Name) * Signature * By checking here, you are consenting to use your electronic signature in lieu of an original signature on paper. Witness Statements * No Yes, and they will be sent to [email protected] All witness statements must be included when remitting AIM report. Completion * Yes, this form is complete. I understand that if it is not, it will not be submitted and could cause delays/refusal of any future insurance or defence fund claims.
