Fillable 150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.gov
Elevator/Escalator
Safety Complaint Form
This form is for reporting a dangerous condition involving an elevator or escalator located in Iowa.
Owners and operators are required to report an incident such as an injury, fire, or explosion using a
separate form.
Please provide as much relevant information as possible in the spaces provided below.
Type of safety complaint: Elevator Escalator
Individual Reporting Complaint Information
Name
Phone number
Email address
Address
State
Zip
Elevator/Escalator Information
Owner’s name
Phone number
Elevator/escalator name
Date and time of activity
Location address
City
State
Zip
What suspicious or unsafe activity occurred?
02.24.2020
100-003
I certify that the information submitted on this form is true and accurate to the best of my
knowledge.
Complainant’s Signature Date
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signature
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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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Completed 13 August 2020

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