Southern Illinois University Edwardsville
Unmanned Aircraft Systems Use Questionnaire for
FAA 333 Exemption and Insurance Underwriting
Instructions
This questionnaire collects information necessary for the university to submit an application to
the FAA for a 333 exemption and for Risk Management to apply for insurance underwriting for
UAS operations.
Use a separate questionnaire for each project involving a UAS. Please complete the questionnaire as
completely as possible. Where detailed information is not known, provide a description of the project
and its personnel, UAS equipment, and location. If the proposed project will be conducted entirely
indoors, please note that in the General Information section. Indoor UAS flights do not require FAA
approval, but do require insurance underwriting.
Projects that are planned for implementation sometime in the future should be described in as much
detail as possible.
General Information
Today’s Date:
Person completing this questionnaire: Name____________________ Email_______________________
Project Name:
Project status: __Ready to begin
__Begin within 6 months
__Begin > 6 months
Project Description (i.e. classroom training, marketing, field work, airframe testing, etc…):
This project will be conducted entirely indoors.  Yes  No
This project is for an academic course.  Yes  No
College/Department:
Proposed Project Dates (if known):
(project beginning date) (project completion date)
Anticipated First Flight Date (if known):
SIUE 11 30 2015
1
Key Personnel
Key Project Personnel (include anyone who will be present during flights, as well as anyone with access
to the data after the flights). If pilots have not yet been identified, indicate likely sources (i.e., SIU
Aviation, volunteer, private pilot).
Name
Role
SIU Affiliation
(faculty, student,
etc.)
Email address
Telephone #
Responsible
University Employee
(required)
1
Pilot-in-Command
(required for outdoor
flights)
For all pilots, complete
Qualifications form
the
separate
UAS
Pilot-Operator
Project Description
Executive Summary of Project:
Project Purpose (include a detailed description of the anticipated use of the UAS):
Risks Associated with Project (provide a detailed discussion of the risks and benefits associated with
the project):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
1
The Pilot-in-Command of a UAS flight PIC must be a licensed pilot and hold a FAA medical certificate as well as a
valid driver’s license.
SIUE 11 30 2015
2
UAS Description
Describe the type(s) of UAS that are to be used for the project. Include as much detail as possible. You
may need to submit copies of manufacturer’s operating manuals but do not submit copies of any
documentation with this questionnaire. If the UAS has not yet been purchased fill in as much
information about the proposed UAS to be purchased.
Make and Model: _____________________________________________________________________
Manufacturers Serial Number: ___________________________________________________________
Date purchased:
New or used?
Price paid. $________
Present estimated value of UAS with all attached equipment and any modifications made since original
purchase: $________
Aircraft type: Fixed Wind Rotor-wing Balloon
Single engine Multi-engine
Other (describe) ______________________________________________________________
Does this UAS burn combustible fuel? Type of fuel?__________________________________________
Type of control:
Manual
Semi-autonomous Fully autonomous
Type of launch:
Traditional takeoff Hand Rail
Other
(describe)_________________________
Type of recovery:
Traditional landing Net/line capture
Parachute
Other (describe) ____________________________________________________
Maximum gross takeoff weight:__________________________________________________________
Wingspan/rotor diameter (specify units): __________________________________________________
Maximum endurance (hours): ___________________________________________________________
Maximum operating altitude (feet): _______________________________________________________
Maximum range (specify units): __________________________________________________________
Does the UAS have an automated recovery program that allows it to safely return to a predetermined
point in the event that the ground control station loses communication with the UAS? Please describe.
___________________________________________________________________________________
Does the UAS have the ability to independently detect and avoid other aerial traffic? ______________
Are there redundancies built in for the UAS propulsion system?________________________________
Are there redundancies built in for the UAS flight control surfaces?______________________________
Are there redundancies built in for the UAS navigation/communications system?__________________
Aircraft manufacturer’s website: _________________________________________________________
Where is UAS normally stored? (Building/Room)__________________________________________
Describe security measures in place at location of storage._________________________________
________________________________________________________________________________
Estimated number of hours UAS will be flown in the coming 12 months.______________________
Estimated number of flights/missions in the coming 12 months._____________________________
SIUE 11 30 2015
3
Type(s) of Sensor Systems to be Utilized
For each of the following check yes or no. In the space provided, please provide a description of the
maximum resolution/range available and the level of detail visible/audible at various heights. (Please
note: You may be asked to provide examples of images, video stills, etc. taken from altitudes at
which the UAS will be flown for this activity.)
Digital camera:  Yes  No
Description:
Video camera:  Yes  No
Description:_
Infrared camera:  Yes  No
Description:_
Microphone:  Yes  No
Description:_
Other (list type, name, and manufacturer):
Description:_
UAS Maintenance
Describe fully the type of maintenance required for the UAS you will be using, who conducts the
maintenance and when the UAS was last serviced.
Project Location
If the UAS will only be flown indoors, please list the building and room in which the flights will occur.
_____________________________________________________________________________________
Outdoor location of Operations (please be specific – provide GPS coordinates if possible):
Distance from nearest airport (specify units) _____________________
Is this Location:
Urban
Rural Populated
Rural Unpopulated
Is this Location: ______University-owned ______Private property ______Government-controlled
If the property is privately-owned or government-controlled, provide the name and contact
information of the owner or government agency.
______________________________________________________
SIUE 11 30 2015
4
Do/will you have signed permission to fly a UAS over private or government property?  Yes  No
You may be asked to provide a copy of the signed agreement or a letter providing permission.
Will the UAS be flown in inclement weather?  Yes  No
After dark?  Yes  No
What additional privacy safeguards will be in place during flights?
□ Buffer zone (list approximate size of the buffer zone):
□ Notifications to adjoining property owners:_ _______________________________________
□ Other: ________________________________________________________________________
How many visual observers will be present for a typical mission? ______
Maximum distance the UAS will fly from ground station? Specify units. _______
Maximum altitude the UAS will be flown (feet). ______
Longest anticipated duration of any single flight (hours). _______
Will the UAS be used outside of the United States?  Yes  No
Will the UAS be flown outside of Illinois?  Yes  No If yes, list other states where it will be flown.
___________________________________________________________________________________
Please send the completed questionnaire to jweinbe@siue.edu
SIUE 11 30 2015
5