Pilots with chronic lymphocytic leukemia or small lymphocytic lymphoma ask the oncologist who manages it to complete this one-page FAA summary. It records whether the diagnosis came at age 40 or older with 5 or more years of oncology follow-up, current stability, Rai and Binet stage, signs of active disease, and labs from the last 90 days. It goes with a current progress note.
The treating oncologist completes and signs the form and adds a name or office stamp. The pilot fills in name, birthdate, applicant ID and PI number.
Download the current version from the source each time; forms change without notice.
Chronic Lymphocytic Leukemia (CLL) / Small Lymphocytic Lymphoma (SLL) Status Summary
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The treating oncologist who manages the pilot's CLL or SLL. The oncologist reports age at diagnosis, years of oncology follow-up, Rai and Binet stage, disease activity and recent labs, then signs and dates it. A current, detailed progress note addressing each item goes with it.
Labs performed no more than 90 days earlier showing the hemoglobin value, platelets above 100,000/microL, and a total or absolute lymphocyte count doubling time greater than 6 months. A copy of the lab results is attached to the summary.