Purpose: USPA collects information on skydiving accidents for the sole purpose of enhancing safety and preventing accidents.

Applicability: This form should be submitted in all cases in which a skydiving incident raises a safety issue, involves an injury requiring attention at a medical facility, or results in a death. It can also be used to report near-accidents or other incidents from which a lesson can be learned.

Instructions: A USPA Safety & Training Advisor or (in the absence of an S&TA) a USPA Instructor assigned by the S&TA should complete this form. In the event of a fatality involving more than one person, please use a separate form for each person.

This form will be submitted to the Director of Safety & Training at USPA Headquarters.

Confidentiality: To ensure confidentiality of both the accident victim and the reporting individual, USPA Headquarters will delete Section 2 of this form's records as soon as any necessary adjustments to the deceased member's data record is made. Do not retain any copies of this form. Note that data submitted in this form is NOT encrypted.

Section 1: Complete for all incidents.

Demographic Information

 Age:   Height:   Exit Weight:   Wing Loading:   Sex: MaleFemale

 Student or USPA License held: StudentA B C D None  Time In Sport:

  Number of jumps: Total: Last 30 days: Last 12 months:

Jump Type

 Student jump (by type): SLIADAFFTandemCoachOther:

 Experienced (check all that apply): Formation Skydiving Freeflying Video Canopy Formation Demo Night Water Freestyle Skysurfing Canopy Swooping Other:

Equipment

Harness and container system: Manufacturer: Model:

Main canopy: Manufacturer: Model: Square feet:

Main packed by: JumperFAA RiggerSupervised Packer Condition:

Reserve Canopy: Manufacturer: Model: Square feet:

AAD: Manufacturer: Model: Turned on? Yes No

Helmet: Yes No Type:

RSL: Yes No Hooked up? Yes No

Visual altimeter: AnalogDigitalNone Location: Wrist Chest Other:

Did the equipment, as far as can be determined, comply with Federal regulations? Yes No

Include any other relevant equipment information (attach a separate document if necessary):

Aircraft Information

Type of aircraft:

Other applicable aircraft and pilot information:

Visibility:   Ceiling:   Surface Winds:   Temperature:

Other applicable weather conditions:

Description of Accident

Provide a description of the incident including factual information obtained from the investigation and any witness accounts. Do not add speculation or conjecture to the investigation report. Attach a separate document(s) below, if necessary. All accompanying documentation will be destroyed with this report.

Section 2: Required for fatal accidents only.

Victim Information

Name of deceased:   USPA membership #:

Address:

Address 2:

City: State: ZIP:

Location of incident:

Date and time of incident:

Investigator Information

Name:   USPA membership #:

Ratings:

Phone number: E-mail:

Date: 05-25-2013

Optional: Documentation.

File Upload

To upload a file, browse to it on your computer. When you have selected the file, click the "Upload" link. When your file has been successfully uploaded, you will receive the confirmation "Your file has been uploaded." When all files are uploaded and this form is complete, click the "SUBMIT" button below.

Attachment #1:

Attachment #2:

Attachment #3:

Submit Report

Submit

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