Boiler and Pressure Vessel Safety
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: Boiler Pressure Vessel
Individual Reporting Complaint Information
Boiler/Pressure Vessel Information
Boiler/pressure vessel name
Date and time of activity
What suspicious or unsafe activity occurred?
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.
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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