HIMS-TRAINED AME DATA SHEET INSTRUCTIONS
(Updated 04/24/2019)
This DATA Sheet is needed for all initial applications, initial applications deferred for
additional information, reapplication after relapse treatment, or seeking monitored
abstinence.
This form is NOT needed for class 3 airmen or requests for program modification.
HARDWARE AND SOFTWARE ENVIRONMENT
• Windows 7 or Windows 10.
• Apple MAC default for opening PDFs is their “Preview” program. It supports filling, but:
o The calendars for the dates do not show up;
o Does not support JavaScript, therefore the “Click to Submit” is not operative.
• Do not use on portable Apple or Android devices.
• Use the latest version of ADOBE ACROBAT READER DC or ADOBE PRO. Some
functions may not work if you are using an old version of ADOBE. Download free Acrobat
Reader DC at https://get.adobe.com/reader/
PROCEDURE
Initial use:
• The recommended best practice is to create an archive template copy.
• Then save another copy as your working template. You will reuse the working template for
each new HIMS DATA Sheet report.
Recurrent use:
• Open the working template document.
• Save it on your system, using “save as” function. Use whatever name comports with your
data protection schema e.g., the airman unique ID (see below).
• Do not overwrite the working template.
• Do not use the airman name on the form or as the external file name. Since the
document will be sent by regular email, using airman’s name either on the form or as the
external file name will constitute spillage of personally protected information (PII).
• Enter the data on the form (instructions below).
• Save the completed document in your protected electronic system and print it.
• A green “Submit Completed Form” button will work with Windows but not MAC
computers.
Our understanding is that this incompatibility has to do with Apple and ADOBE vs Microsoft
and Adobe.
• You do not have to sign the electronic document.
For APPLE Computers: Skip the next sections and go to “FOR APPLE MAC Computers.”
For Microsoft Windows computers - go to “FOR WINDOWS” below:
FOR WINDOWS:
• When clicking the “Submit” button you will see:
• This is a reminder if you did not do the save as recommended above.
If you did, click “Yes.” If not, click “No” and save the file as instructed, then click the
submit button again.
• After clicking “Yes,” you will see a prompt for the email information.
Make sure your email application is OPEN.
• If you are using Outlook, select the “Default mail application (Microsoft Outlook)” button,
as shown below, and click “Continue.” Go to “PRINT.” If not using Outlook go to the “Other
than Outlook email” section in this document.
If using other than Outlook email:
• Select “Use Webmail.”
• Click the drop down arrow.
• ADD a Gmail account name or any other email address of your email system. Enter the account
the name. (Note: “verizom” used above is intentional to avoid using a proprietary name.)
• Click “Remember my choice” to include it in the dropdown list for the future.
•
Click “Continue.” Go to “PRINT.”
PRINT:
The system will then open the print function. The hard copy DATA Sheet must be included in the
paper HIMS package sent to the FAA, per the HIMS AME checklist.
Window users - skip the section below and go to the “HOW TO ENTER FORM DATA” section.
FOR APPLE MAC COMPUTERS
• Open your email application program
• Email the saved version to 9-AVS-AAM-HIMSDATA@FAA.GOV as an attachment.
• Print a hard copy. The hard copy DATA Sheet must be included in the paper HIMS package
sent to the FAA, per the HIMS AME checklist.
HOW TO ENTER FORM DATA
• All fields surrounded with a red box require a response.
• Before you begin, make sure the drop-down boxes are set to the first selection in the
template document. The first selection should show the word “select” or appear blank. If not,
you can reset it to the first selection.
Demographic Information
TOP
PI # - Only if known.
Airman unique ID - A unique set of characters that will allow the FAA to match
the emailed DATA Sheet with the hard copy chart submitted. e.g., the AME
electronic record number, chart number, airman’s initials and 4 characters of the
airmen driver’s license, or social security number.
Resubmit Initial Deferred - If this case was previously rejected for an SI on the
initial.
1.
Select from drop-down menu the pilot’s gender. Enter age in years (whole
numbers).
2.
Select from the drop-down menu the number range of active pilots employed by
the airman’s employer.
Family History
3.
Select yes/no to indicate family history of substance abuse. If yes and known,
enter diagnosis and preferred substance.
Treatment Information
4.
Date entered current treatment: This is the date the airman started treatment
(not the date AME started monitoring). Format MM/YY.
Select name of treatment center from drop-down menu. If not listed, select
“other” and enter it manually in the adjacent box.
4a.
If yes, complete fields as indicated.
4b.
Check all that apply. Other legal events include public intoxication, etc.
If intervention occurred, identify type (family, peer, or other).
Any category test (pre-employment, random, post-accident, etc., is a DOT/FAA
test).
4c.
Select monitored abstinence if airman only received education and monitoring
by AME. Self-directed - e.g., 12 step program.
Substance History
5.
Select yes/no for nicotine use. If applicable, list approximate date quit. Format
MM/YY.
5a.
Select from the drop-down menu airman’s preferred substance(s). Rank in
order.
5b.
Check all drug (s)/substance(s) abused by this airman.
Psychiatric history
6.
Check all that apply; any co-morbid psychiatric conditions.
6a.
For other additions such as gambling or sexual, select “Behavioral disorders(s).”
Comments
Clarification or AME notes.
