Fillable Conv.acc 0 Elevator Or Escalator Accident (Office of the Chief Information Officer)

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Conv.acc 0 Elevator Or Escalator Accident (Office of the Chief Information Officer)

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File type: PDF

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BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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Conveyance 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
Elevator Safety
Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
elevators@iwd.iowa.gov
www.iowaelevators.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:
Owner’s name
Owner’s ID
State ID
Manufacturer
Accident building address
City
State
Zip
Owner’s address
City
State
Zip
Phone number
Fax number
Email address
Type of conveyance: Escalator Elevator Special purpose Other:
Describe in detail what happened:
The owner or duly authorized agent shall immediately notify the Labor Commissioner of each and every personal injury accident requiring the
care of a physician, or causing disability exceeding one day, or causing damage to the conveyance exceeding $2,000.00. Notification shall be
in writing, shall specifically identify the conveyance, state identification number, owner and description of accident. When a personal injury
involves the failure or destruction of any part of the conveyance or the operating mechanism of a device, the use of the device is forbidden
until it has been made safe and has been re-inspected. Any repairs or alterations shall be approved by the Labor Commissioner. The removal
of any part of the damaged conveyance or operating mechanism from the premises is forbidden, until permission to do so has been granted
by the Labor Commissioner.
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
Are repairs needed now? Yes No
(If yes, attach details of repairs needed)
Does the conveyance have a permit to operate? Yes No
Date of last inspection:
Has conveyance been secured from operation? Yes No If no, why?
Has conveyance contractor been notified? Yes No If yes, name/phone number:
Page 1
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
If minor, parent/guardian name
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
600-007
09.14.2018
Page 2
Witnesses
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Name
Address
Phone number
Age
Conveyance 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 www.iowaelevators.gov under Quick Links.
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Conv.acc 0 Elevator Or Escalator Accident (Office of the Chief Information Officer)

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Completed 20 July 2020

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