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Amusement Ride Safety 150 Des Moines Street Des (Office of the Chief Information Officer)

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BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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Amusement Accident 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
Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
amusement@iwd.iowa.gov
amusement.iowa.gov
FOR OFFICE USE ONLY
Received date: Time:
Notified date: Time:
Filed on time: Yes No
First responder written report: Yes No
Hospital report: Yes No
Initials:
Ride name
Ride type (thrill/inflatable/kiddie)
ID#
Accident date/time
Operator’s name
Phone number
City
State
Zip
Describe in detail what happened:
The operator shall immediately report by phone a fatality or an accident that requires medical care more than first aid. An operator
shall report in writing to the Labor Commissioner an accident resulting in injury within 48 hours after occurrence of the incident. The report of
an accident shall include this completed form and a copy of the report submitted to insurance companies. The Labor Commissioner may
require that the scene of an accident be secured and not disturbed more than necessary for removal of deceased or injured persons. If covered
equipment is removed from service by the Labor Commissioner, the Labor Commissioner shall order an immediate investigation and the
covered equipment shall be released for repair and operation only after a complete investigation.
The covered equipment may not be returned to service until it successfully passed a complete inspection.
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 the operator have a permit to operate? Yes No
Are repairs needed now? Yes No
(If yes, attach details of repairs needed)
Has ride been secured from operation? Yes No If no, why?
Has operator been notified? Yes No If yes, name/phone number:
100-004
09.14.2018
Page 1
12
12
12
12
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
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
100-004
Page 2
Witnesses
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Amusement Accident Report
I certify that the information on this form and attachments (if any) is true and accurate to the best of my knowledge.
Name of Person Filing Report Phone Number 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 amusement.iowa.gov under Quick Links.
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Amusement Ride Safety 150 Des Moines Street Des (Office of the Chief Information Officer)

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Completed 20 July 2020

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