Type of Inspection:
Annual Inspection Re-inspection Division of Labor
Iowa Division of Labor
Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Complete a separate form for each inflatable, blower, and generator then submit it the Division of Labor.
Inflatable Amusement Device Inspection Report
Repair Due Date:
Location of inspection (address, city and zip)
Name of device (Ex: ninja jump, generator 1, blower B)
S = Satisfactory US = Unsatisfactory – Safety Order issued C = Corrected on Site NA = Not Applicable
Generator: Condition Grounding Ground Fault Protection
Fueling Location Fire Extinguisher
Extension Cords: Grounding Proper Size Setup Location (suitability)
Blower: Plug Ground Guarding Placement
Ground Fault Protection
Inflatable: Placement Stitching Condition Tie Downs
Operations: Safety Rules Posted Attendant on Duty Operations Manual Available
Signature of Owner or Authorized Representative Date Signature of Owner Designated Inspector Date
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
I certify that the information on this report is true and accurate to the best of my knowledge.