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Submitter & Facility

Is this report associated with an Aircraft accident? *

Yes No

Do you allow ATSAP to transfer a copy of this report to NASA ASRS? *

Yes No

ASRS requires that a Submitter Contact Information and Address are provided with a copy of the report. Please make sure your Address information is correct or add any missing data.

Address 1 *

Address 2

City *

State *

Zip *

Home Phone *
Would you like to share a de-identified copy of this report with your facility's Local Safety Council?

Yes No
Time Estimated
1. Date and time event occurred *

Date:

Time:
2. Date and time submitter aware of event *

Date:

Time:
3. Total CPC years at facility *
4. Total Years ATC experience *
5. Position of Record *
6. Facility ID and Type *

ID:

Type:
7. Control position(s) worked at the time of the event (check all that apply) *

Assistant Cab Coordinator Clearance Delivery FLM/CIC Flight Data Gate Hold/Metering Ground 1 Ground 2 Ground 3 Local 1 Local 2 Local 3 OM Other TMC Tower Radar
8. Sector *

Sector Name(s):

Sector or position number(s):
9. In your opinion, was time on position or high workload a contributing factor to the event? *

Yes No

a. At time of event, approximately how long had you been on duty? *

b. At time of event, approximately how long had you been on position? *

c. At time of event how many breaks had you taken since start of shift?*
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