Boiler and Pressure Vessel Incident Report
Equal Opportunity Employer/Program
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Iowa Division of Labor
Boiler and Pressure Vessel Safety
1000 East Grand Avenue
Des Moines, IA 50319-0209
Date: Time: Initials:
Notified Date: Time:
First responder written report: Yes No
Hospital report: Yes No
Filed within 48 hours: Yes No
Location name (if different than owner)
Describe in detail what happened:
Use this form to report a boiler or pressure vessel explosion. Also file this form if a boiler or pressure vessel causes an acute
illness, an injury that needs professional medical care, or a disability that lasts more than one day. Report by calling
515-725-5607 or 515-725-5609 and if requested, complete this form. 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 may be prohibited by law.
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 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: