Iowa Division of Labor
150 Des Moines Street
Des Moines, IA 50309-1836
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
Please provide as much relevant information as possible in the spaces provided below.
Type of safety complaint: Elevator Escalator
Individual Reporting Complaint Information
Date and time of activity
What suspicious or unsafe activity occurred?
I certify that the information submitted on this form is true and accurate to the best of my
Complainant’s Signature Date
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