Drone Risk Assessment Form

• Conducted on

  Date

• Prepared by

• Project or Department:

• Responsible Pilot in Command:

  Nick Ambrosino

  Kim Bulman

  Devan Gehrlein

  Luke O'Brien

• Date or expected frequency of mission(s):

• Specific Location:

• Description of Operation:

• As necessary, include a sketch or diagram showing the planned sUAS flight path or area of operations. Sketch should include home point, observation points, applicable right of ways and property lines, and known hazards.

• Attachments:

  Media

Explain Risk Mitigation measures for all Medium (yellow) and High (red) risks.

• Complexity of Mission:

  Simple

  Moderate

  Complex

• DOC experience with mission type:

  Highly experienced

  Performed < 5 times

• Controlled Airspace:

  Class B-D

  Class E

  Class G

• Private Property:

  N/A or Permission

  Nearby > 50 ft

  Over or < 10 ft from it

• Daylight:

  Daytime only

  During dusk/dawn

  Nighttime

• Wires/Trees/Structures:

  Not present

  Nearby > 100 ft

  Present

• Drone Distance from Operator:

  Select Vertical Distance < 300 ft Vertical Distance > 300 ft Horizontal Distance > 400 yards

  • Vertical Distance < 300 ft
  • Vertical Distance > 300 ft
  • Horizontal Distance > 400 yards

• Proximity to Roads:

  Not over open roadways

  Open road < 40 ft

  Over open roads

• Proximity to Radio Towers:

  Not present

  Nearby > 100 ft

  Present

• Nearby Airport/Heliport:

  None nearby > 3 miles

  Nearby 1-3 miles

  Close Proximity < 1 mile

• Pedestrians/distraction:

  Not present

  Nearby uncontrolled

  Close Proximity

• Over Water:

  Not over water

  Near water

  Over water

• GPS/Radio Dead Spots:

  Unlikely

  Possible

  Likely

Overall Site Risk Rating

• Fill in highest rating from the above inspection:

  Low

  Medium

  High

Signature

• Responsible PIC:

  Sign

• Drone Manager:

  Sign

• Superintendent?

  Sign