Form 2120-0707 FAA Aerospace Medical Certification Services Pilot Satis

Airman Medical Certification Services

OMB CONTROL NUMBER: 2120-0707

EXPIRATION DATE: May 31, 2019

Paperwork Reduction Act Statement.

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0707. Public reporting for this collection of information is estimated to be approximately 10-15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information.

All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524

2018 Airman Feedback Survey

An Airman Medical Certification Services (AMCS) 2018 Airman Feedback Survey is attached. If you have already completed the survey online, thank you for your feedback.

You will be evaluating the quality of airman medical certification services provided by:

• Your Aviation Medical Examiner (AME)

• Your Regional Flight Surgeon (RFS) Office

• The Aerospace Medical Certification Division (AMCD) in Oklahoma City

You will also evaluate your use of MedXPress (OMB control No. 2120-0707).

The FAA’s Civil Aerospace Medical Institute (CAMI) strictly adheres to ethical standards, public law, and federal policies for safeguarding the confidentiality of all participants in this survey. All data provided will be kept private in accordance with the law. This survey is hosted by a contractor, Cherokee CRC, LLC. The contractor will deliver a data file to the FAA for analysis. That data file will not contain any personally identifying information. Only analyses and reports of aggregate data will be produced and released.

Participation in the survey is completely voluntary.

For your convenience, you may complete the survey online using your computer or mobile device, or complete and return the attached paper survey. Submit only one survey.

To access the online survey, either scan the QR code using your mobile device or go to the Internet and type the following into the web address bar: tinyurl.com/airman18

At the survey log in screen, enter this password: «Username» (use upper-case letters) and click the ‘Next’ button.

In the event the envelope is missing, mail your completed paper survey to:

FAA Airman Survey (AAM-510)

CAMI, Rm 250D

PO Box 25082

Oklahoma City, OK 73125

This page intentionally left blank.

Your thoroughness and honesty in completing the survey are appreciated. Your feedback will help us improve medical certification services offered to all airman applicants.

Participation is voluntary and anonymous. Your responses will be kept private to the extent provided by law.

Instructions: Read each item carefully then mark the response that best describes your most recent application for an airman medical certificate.

     Note: Some items require a response in order to skip items not relevant to you.

Based on your most recent application for airman medical certification:  

1. Which airman medical certificate did you apply for? (response required)

• Class I

• Class II

• Class III

• Third Class (Basic Med) Medical Reform

• I have never applied for an airman medical certificate. (Stop here and return your survey. Thank You!)

2. How many months ago did you submit your application?

• 0-3 months

• 4-6 months

• 7-9 months

• 10-12 months

• 13 months or more

3. How many miles did you travel one way for the exam appointment with your aviation medical examiner (AME)?

• 0-24 miles

• 25-50 miles

• 51-75 miles

• 76-100 miles

• 101 miles or more (explain below)

Reason(s) for traveling 101 miles or more for your appointment: ___________________________________________

______________________________________________________________________________________________

4. How many AMEs did you contact before making your exam appointment?

• 1

• 2

• 3

• 4

• 5 or more

5. Is your AME your primary care doctor?

• Yes

• No

Based on your most recent application for airman medical certification:  

6. What was the basis for selecting your AME? [mark all that apply]

• Referred by flight instructor or school

• Referred by airline or AME employed by airline

• Referred by pilot

• Referred by doctor or previous AME

• Performed my previous medical certification exam(s)

• Is my primary care doctor

• Makes quick certification decisions

• Licensed to perform needed service (Class I exam, special issuance, etc.)

• Handles complex cases

• Nearest location

• Earliest available appointment

• Low cost

• Other reason(s) (explain below)

Other reason(s) for selecting your AME: _____________________________________________________________

_____________________________________________________________________________________________

7. Did the AME’s office tell you to bring the following to your exam appointment?

	Yes	No, but did need for exam	No, not needed for exam	Do not remember
Valid photo ID				
MedXPress confirmation number				
Printout of completed Summary Sheet from MedXPress				
List of your medications				
Medical history details (e.g., dates of hospitalizations and medical exams)				
Current medical tests/lab results				
Past medical tests/lab results				
Special issuance paperwork				
SODA (statement of demonstrated ability) paperwork				
Conditions AMEs Can Issue (CACI) paperwork……………				

8. Did you use MedXPress to submit your application? (response required)

• Yes

• No (skip to item 16, on page 4)

• Do not remember (skip to item 16, on page 4)

Note: Answer item 9 only if you answered ‘Yes’ on item 8.

9. Did your AME’s office ask you to provide your MedXPress Summary Sheet before your exam appointment? (response required)

• Yes

• No (skip to item 11, on the next page)

• Do not remember (skip to item 11, on the next page)

Based on your most recent application for airman medical certification:  

Note: Answer item 10 only if you answered ‘Yes’ on item 9.

10. Based on their receipt of your MedXPress Summary Sheet, did your AME’s office ask you to bring additional documentation to your exam appointment?

• Yes

• No

• Do not remember

11. Overall how satisfied were you with the performance of MedXPress?

• Very dissatisfied (explain below)

• Dissatisfied (explain below)

• Neither dissatisfied nor satisfied

• Satisfied

• Very satisfied

Please explain why you were dissatisfied with the performance of MedXPress: _______________________________

______________________________________________________________________________________________

12. How did MedXPress perform compared to your expectations?

• Far below expectations (explain below)

• Below expectations (explain below)

• Met expectations

• Above expectations

• Far above expectations

Please explain why MedXPress performed below your expectations: _______________________________________

______________________________________________________________________________________________

13. Overall how would you rate the performance of MedXPress?

• Very poor

• Poor

• Average

• Good

• Excellent

14. Did the AME access your MedXPress form online during the exam appointment? (response required)

• Yes (skip to item 16, on the next page)

• No

• Do not know (skip to item 16, on the next page)

• Do not remember (skip to item 16, on the next page)

Note: Answer item 15 only if you answered ‘No’ on item 14.

15. What was the main reason the AME did not access your MedXPress form online during the exam appointment?

• I did not have my confirmation number

• My confirmation number had expired

• The AME was not accepting MedXPress

• The AME did not require MedXPress

• Other reason (explain below)

Other reason the AME did not access your MedXPress form online during the exam appointment: ______________

____________________________________________________________________________________________

Based on your most recent application for airman medical certification:  

16. During your exam appointment, who did each of the following: (response required) [mark all that apply]

	No one	AME	Another physician (not the AME)	Physician’s Assistant	Nurse	Other office personnel	Do not remember
Reviewed your medical history with you							
Performed your physical exam							

Note: Answer item 17 only if you answered ‘AME’ on item 16.

17. To what extent did your AME do each of the following during your exam appointment?

	Not at all	Limited extent	Moderate extent	Considerable extent	Great extent	N/A
Obtain a comprehensive history						
Discuss safety risk(s) of current medical condition(s)						
Explain the certification process and airman appeal rights						
Discuss safety risk of over-the-counter (OTC) medications and supplements						
Discuss mental health						
Discuss sleep patterns						

Note: Answer item 18 only if you answered ‘AME’ performed your physical exam on item 16.

Did your AME...	Yes	No
perform a thorough medical exam?………		
examine your eyes and ears with a medical device?		
have you remove or undo articles of clothing for the exam?		
listen to your heart and lungs?		

Note: Answer item 19 only if you answered ‘AME’ on item 16.

To what extent did your AME...	Not at all	Limited extent	Moderate extent	Considerable extent	Great extent	N/A
provide a professional setting for the medical exam, including cleanliness and appearance?						
charge appropriately for services?						
clearly explain your responsibilities in the medical certification process?						
provide you with all the information you requested?						
provide information you requested in a timely manner?						
provide you with accurate information?						
treat you with courtesy and respect?						

20. During your most recent medical certification exam, did your AME alert you to any new health condition(s)? (response required)

• Yes

• No (skip to item 22)

Note: Answer item 21 only if you answered ‘Yes’ on item 20.

21. Did the new health condition(s) require treatment for medical certification?

• Yes

• No

22. During your most recent medical certification exam, did your AME alert you that a preexisting health condition(s) required treatment to obtain your medical certification? (response required)

• Yes

• No (skip to item 24)

Note: Answer item 23 only if you answered ‘Yes’ on item 22.

23. Did you receive treatment for the preexisting health condition(s)?

• Yes

• No

24. During any previous medical certification exam, did your AME alert you to any new health condition(s)? (response required)

• Yes

• No (skip to item 26)

Note: Answer item 25 only if you answered ‘Yes’ on item 24.

25. Did the new health condition(s) require treatment for medical certification?

• Yes

• No

26. During any previous medical certification exam, did your AME alert you that a preexisting health condition(s) required treatment to obtain your medical certification? (response required)

• Yes

• No (skip to item 28, on the next page)

Note: Answer item 27 only if you answered ‘Yes’ on item 26.

27. Did you receive treatment for the preexisting health condition(s)?

• Yes

• No

Based on your most recent application for airman medical certification:

28. Overall how satisfied were you with your exam appointment? (response required)

• Very dissatisfied

• Dissatisfied

• Neither dissatisfied nor satisfied (skip to item 30)

• Satisfied (skip to item 30)

• Very satisfied (skip to item 30)

Note: Answer item 29 only if you answered ‘Very dissatisfied’ or ‘Dissatisfied’ on item 28.

29. Why were you dissatisfied with your exam appointment? [mark all that apply]

• AME did not issue my certificate during the exam appointment

• The exam was not thorough

• Not examined in a professional environment

• AME conducted the exam at a different location than listed in the FAA directory

• I had to remove articles of clothing

• Not treated with courtesy and respect

• Other reason(s) (explain below)

Other reason(s) you were dissatisfied with your exam appointment: ______________________________________

____________________________________________________________________________________________

30. Overall how satisfied were you with the quality of service provided by your AME? (response required)

• Very dissatisfied

• Dissatisfied

• Neither dissatisfied nor satisfied (skip to item 32)

• Satisfied (skip to item 32)

• Very satisfied (skip to item 32)

Note: Answer item 31 only if you answered ‘Very dissatisfied’ or ‘Dissatisfied’ on item 30.

31. Why were you dissatisfied with the quality of AME services? [mark all that apply]

• AME did not issue my certificate during the exam appointment

• AME lacked knowledge of current airman medical certification standards

• Not informed of required documentation to bring to the exam

• Not informed of additional documentation that the FAA would require to issue my certificate

• Not informed of status of my application

• Other reason(s) (explain below)

Other reason(s) you were dissatisfied with the quality of AME services: __________________________________

___________________________________________________________________________________________

32. Based on your most recent experience with your AME, to what extent does the FAA airman medical certification process ensure the safety of the National Airspace System? (response required)

• Not at all

• Limited extent

• Moderate extent

• Considerable extent (skip to item 34, on the next page)

• Great extent (skip to item 34, on the next page)

Note: Answer item 33 only if you answered ‘Not at all,’ ‘Limited extent,’ or ‘Moderate extent’ on item 32.

33. What is the main reason for responding [‘Not at all,’ ‘Limited extent,’ or ‘Moderate extent’] to the question asking to what extent the FAA airman medical certification process ensures the safety of the National Airspace System?

• Exam is not comprehensive enough to adequately screen pilots

• Not all AMEs perform thorough exams

• Deters pilots from applying for medical certification

• Encourages pilots to be dishonest on application for medical certification

• Other reason (explain below)

Other reason for your response: ________________________________________________________________

__________________________________________________________________________________________

Note: Answer item 34 only if you answered ‘Considerable extent’ or ‘Great extent’ on item 32.

34. What is the main reason for responding [‘Considerable extent’ or ‘Great extent’] to the question asking to what extent the FAA airman medical certification process ensures the safety of the National Airspace System?

• Ensures pilots are medically safe to fly

• Deters pilots from flying, if not medically qualified

• Other reason (explain below)

Other reason for your response: ________________________________________________________________

__________________________________________________________________________________________

35. Was your medical certificate issued on the same day as your exam appointment? (response required)

• Yes (skip to item 47, on page 9)

• No

Note: Answer item 36 only if you answered ‘No’ on item 35.

36. Which of the following best describes the processing of your application for a medical certification? (response required)

• The AME required additional information before issuing my certificate

• The AME deferred my application for review to the Regional Flight Surgeon (RFS) or to the Aerospace Medical Certification Division (AMCD) in Oklahoma City (skip to item 39, on the next page)

Note: Answer item 37 only if you answered ‘AME required additional information’ on item 36.

37. Did your AME explain to you the requirements for additional documentation to meet FAA standards?

• Yes

• No

• Do not remember

Note: Answer item 38 only if you answered ‘No’ on item 35.

38. How long did the AME tell you it would take to receive a decision regarding your medical certification?

• Did not say

• 2-10 days

• 11-30 days

• 31-90 days

• 91 days or more

• Do not remember

Note: Answer item 39 only if you answered ‘AME deferred my application’ on item 36.

39. Which of the following best describes what happened after the AME deferred your application to the RFS or the AMCD in Oklahoma City? (response required)

• No additional information was requested from me before being issued my certificate

• I had to supply additional information, and then was issued my certificate

• I have been contacted by the FAA and my application is still under review (skip to item 41)

• I was denied a medical certificate (skip to item 41)

• I have not been contacted by the FAA (skip to item 47, on page 9)

Note: Answer item 40 only if you answered ‘No additional information was requested’ or ‘I had to supply additional information’ on item 39.

40. How long did it actually take to receive a decision on your medical certification?

• 2-10 days

• 11-30 days

• 31-90 days

• 91 days or more

• Do not remember

Items in this section (41 through 46) ask about your experiences with FAA medical representatives during your most recent application for airman medical certification.

41. Did you have contact with a medical representative concerning issuance of your medical certificate at any of the following FAA offices? [mark all that apply]

	No contact	Phone	E-mail	Postal mail
Regional Medical Division/Regional Flight Surgeon (RFS) Office				
Aerospace Medical Certification Division (AMCD) – Oklahoma City				
Office of Aerospace Medicine – Washington, DC				

Note: Answer items 42 through 46 only if you were contacted (phone, E-mail, or postal mail) by a medical representative concerning issuance of your medical certificate.

42. What was the longest time that the FAA medical representative(s) told you it would take to receive a decision on your medical certificate?

• Did not say

• 2-10 days

• 11-30 days

• 31-90 days

• 91 days or more

• Do not remember

43. To what extent did the FAA medical representative(s) you had contact with…

	Not at all	Limited extent	Moderate extent	Considerable extent	Great extent	N/A
clearly explain your responsibilities in the medical certification process?						
provide you with all the information you requested?						
provide information you requested in a timely manner?						
provide you with accurate information?						
treat you with courtesy and respect?						

44. Overall how satisfied were you with the quality of services provided by the FAA medical representative(s)? (response required)

• Very dissatisfied

• Dissatisfied

• Neither dissatisfied nor satisfied (skip to item 46)

• Satisfied (skip to item 46)

• Very satisfied (skip to item 46)

Note: Answer item 45 only if you answered ‘Very dissatisfied’ or ‘Dissatisfied’ on item 44.

45. Why were you dissatisfied with the quality of services provided by the FAA medical representative(s)? 

[mark all that apply]

• Denied my medical certificate

• Not treated with courtesy and respect

• Not adequately informed of requirements for additional documentation

• Failed to explain requirements for additional documentation

• Not informed of status of application

• Poor communication on where application was in the review process

• Took too long to complete the review

• Other reason(s) (explain below)

Other reason(s) you were dissatisfied with quality of services provided by the FAA medical representative(s):________

______________________________________________________________________________________________

46. Based on your most recent experience with the FAA medical representative(s), to what extent does the FAA airman medical certification process ensure the safety of the National Airspace System?

• Not at all

• Limited extent

• Moderate extent

• Considerable extent

• Great extent

Items in this section (47 through 51) ask about your current airman medical certification, pilot certificate(s), ratings, and employment.

47. What year was your most recent FAA medical certification examination?

2013	2016
2014	2017
2015	2018

48. Which pilot certificate(s) do you currently hold? [mark all that apply]

Student	Private
Sport	Commercial
Recreational	Airline Transport

49. Which rating(s) do you currently hold? [mark all that apply]

• Do not hold any rating

• Instrument Flight Rules (IFR)

• Certified Flight Instructor (CFI)

• Other rating(s) (explain below)

Other rating(s) you currently hold: __________________________________________________________________

_____________________________________________________________________________________________

50. Are you currently employed as a pilot? (response required)

• Not employed as a pilot (skip to item 52)

• Part-time pilot

• Full-time pilot

Note: Answer item 51 only if you answered ‘Part-time pilot’ or ‘Full-time pilot’ on item 50.

51. Is your employment as a pilot with a certificated operator conducting flights under the following?

[mark all that apply]

• Part 61 (Sport pilot)

• Part 91 (Corporate)

• Part 121 (Flag, domestic, supplemental operations)

• Part 125 (Aircraft with 20 or more seats and cargo payload of 6,000 pounds or more when common carriage is not involved)

• Part 129 (Foreign air carrier & foreign operator of US-registered aircraft used in common carriage)

• Part 133 (Rotorcraft external loads)

• Part 135 (Commuter/On-demand operations)

• Part 137 (Agricultural operations)

• Part 141 (Pilot schools)

• Part 142 (Training centers)

• Other Part or Operation (explain below)

Other Part or Operation employing you as a pilot: _____________________________________________________

_____________________________________________________________________________________________

52. Are you aware of the new Third Class (Basic Med) Medical Reform under the FAA Extension, Safety, and Security Act of 2016? (response required)

• Yes

• No (skip to item 54)

Note: Answer item 53 only if you answered ‘Yes’ on item 52.

53. Do you plan to take advantage of the new Third Class (Basic Med) Medical Reform under the FAA Extension, Safety, and Security Act of 2016?

• Yes

• No

54. Which region handled your most recent application for airman medical certification? (response required)

• Alaskan (Alaska)

• Central (Iowa, Kansas, Missouri, Nebraska)

• Eastern (Delaware, Maryland, New Jersey, New York, Pennsylvania, Virginia, West Virginia)

• Great Lakes (Illinois, Indiana, Michigan, Minnesota, North Dakota, Ohio, South Dakota, Wisconsin)

• New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont)

• Northwest Mountain (Colorado, Idaho, Montana, Oregon, Utah, Washington, Wyoming)

• Southern (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee)

• Southwest (Arkansas, Louisiana, New Mexico, Oklahoma, Texas)

• Western-Pacific (Arizona, California, Hawaii, Nevada)

55. Do you have any additional feedback for the FAA, beyond what you have already provided, regarding airman medical certification services? [mark all that apply]

• Recommendation for improvement

• Compliment

• General comment

• Nothing more to add

Use the following boxes to provide additional feedback as marked above. [Note: This survey is hosted by a contractor, Cherokee CRC, LLC. The contractor will deliver a data file to the FAA for analysis. That data file will not contain any personally identifying information. However, if the nature of your comment is specific to you, your confidentiality cannot be assured. Comments are subject to the Freedom of Information Act.]

Recommendation for improvement(s):

Compliment(s):

Complaint(s):

General comment(s):