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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Boiler and Pressure Vessel Incident Report
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.
Iowa Division of Labor
Boiler and Pressure Vessel Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5609/515-725-5610
Fax: 515-242-5076
boilers@iwd.iowa.gov
www.iowaboilers.gov
FOR OFFICE USE ONLY
Date: Time: Initials:
Notified Date: Time:
First responder written report: Yes No
Hospital report: Yes No
Filed within 48 hours: Yes No
Owner name
Jurisdiction number
Accident date/time
Location name (if different than owner)
Phone number
Object address
State
Zip
Describe in detail what happened:
Use this form to report a boiler or pressure vessel explosion. File this form if a boiler or pressure vessel explodes or a
malfunction causes an acute illness or injury that needs professional medical care, or a disability that lasts more than one day.
Report by calling 515-725-5609 or 515-725-5610. An incident that occurs during Division of Labor office hours must be reported
by close of business on the day of the incident. An incident that occurs when the Division of Labor is closed must be reported by
close of business on the next Division of Labor business day. Removal of damaged parts or use of the object is prohibited by
Iowa Administrative Code.
.
Number of people injured:
Are there videotapes or photographs of the incident? Yes No (If yes, send copies)
Were safety orders issued at the last inspection? Yes No
Date of last inspection:
Does boiler or pressure vessel have an operating certificate? Yes No
Are repairs needed now? Yes No
(If yes, attach the details of repairs needed)
Has boiler or pressure vessel been secured from operation? Yes No If no, why not?
Have the local authorities been notified? Yes No If yes, name/phone number:
222-003
02.04.2020
Page 1
People Injured
1. Name
Age
Phone number
Address
City
State
Zip
Email address
If minor, parent/guardian name
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
2. Name
Age
Phone number
Address
City
State
Zip
Email address
If minor, parent/guardian name
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
3. Name
Age
Phone number
Address
City
State
Zip
Email address
If minor, parent/guardian name
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
222-003
02.04.2020
Page 2
Witnesses
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Boiler and Pressure Vessel Incident Report
I certify that the information on this form and the attachments (if any) is true and accurate to the best of my
knowledge.
Name of Person Filing Report Company or Firm Name Signature Date
Please complete a set of questions for each injured person, if number of injured is more than 3, an
additional injured report can be found at www.iowaboilers.gov under Quick Links.
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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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