Amusement Accident Report
Equal Opportunity Employer/Program
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Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Received date: Time:
Notified date: Time:
Filed on time: Yes No
First responder written report: Yes No
Hospital report: Yes No
Ride type (thrill/inflatable/kiddie)
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
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: