Conveyance Accident Report
Equal Opportunity Employer/Program
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Iowa Division of Labor
Mailing address: 1000 East Grand Avenue, Des Moines, IA 50319-0209
Physical address: 150 Des Moines Street, Des Moines, IA 50309 (FedEx/UPS)
Received date: Time:
Notified date: Time:
Filed on time: Yes No
First responder written report: Yes No
Hospital report: Yes No
Accident building 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
Has conveyance been secured from operation? Yes No If no, why?
Has conveyance contractor been notified? Yes No If yes, name/phone number: