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Boiler and Pressure Vessel Safety 150 Des Moines (Office of the Chief Information Officer)

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Iowa Division of Labor
Boiler and Pressure Vessel Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5609/515-725-5610
Fax: 515-242-5076
boilers@iwd.iowa.gov
www.iowaboilers.gov
Boiler/Pressure Vessel
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
separate form.
Please provide as much relevant information as possible in the spaces provided below.
Type of safety complaint: Boiler Pressure Vessel
Individual Reporting Complaint Information
Name
Phone number
Email address
Address
State
Zip
Boiler/Pressure Vessel Information
Owner’s name
Phone number
Boiler/pressure vessel name
Date and time of activity
Location address
City
State
Zip
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.
100-003
02.04.2020
I certify that the information submitted on this form is true and accurate to the best of my
knowledge.
Complainant’s Signature Date
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signature
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Boiler and Pressure Vessel Safety 150 Des Moines (Office of the Chief Information Officer)

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Completed 20 July 2020

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