Pilots treated with insulin who are certified under the third-class option without a continuous glucose monitor have the provider who treats their diabetes complete this two-page FAA report. It records the last diabetes visit, the latest medication change, four quarterly A1C values, a review of glucose self-monitoring data, the insulin schedule and other medications, and yes or no screens for hypoglycemia and end organ disease.
The provider who treats the pilot's diabetes completes and signs it. The pilot fills in name, birthdate, applicant ID, PI number and class applied for, and circles initial or re-certification.
Download the current version from the source each time; forms change without notice.
Diabetes on Insulin Re-Certification Status Report NON CGM - Third Class Option
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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Four quarterly hemoglobin A1C values with dates. Each must be drawn more than 30 days after a diabetes medication change and within 90 days of recertification. The provider also gives the date of the most recent medication change and describes what was changed.
Item 9 asks whether the pilot had any episode of hypoglycemia in the past year that required assistance from another person. A yes answer must be explained with an attached narrative, test results or other records, as with any other yes answer on the form.