Fillable Elevator Safety 150 Des Moines Street Des Moines, (State of Iowa - OCIO)

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Elevator Safety 150 Des Moines Street Des Moines, (State of Iowa - OCIO)

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Conveyance Accident Report
Iowa Division of Labor
Elevator Safety
150 Des Moines Street
Des Moines, IA 50309-1836
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 date/time
City
State
Zip
City
State
Zip
Phone number
Fax number
Email address
Type of conveyance: Escalator Elevator Special purpose Other:
Describe in detail what happened:
The owner shall promptly notify the Labor Commissioner if a personal injury accident requires the service of a physician; if a personal injury
accident causes disability exceeding one day; or, if a conveyance suffers damage that will require more than one hour of mechanic's time
(excluding travel) to repair. Notification shall be in writing and shall include the state identification number, owner, and description of the
accident. If a report is required and any part of the conveyance or its operating mechanism has failed or been destroyed, the use of the
conveyance is forbidden until it has been inspected and approved by the Labor Commissioner. The removal of any part of the damaged
conveyance or operating mechanism from the premises is forbidden until permission 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
02.21.2020
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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Elevator Safety 150 Des Moines Street Des Moines, (State of Iowa - OCIO)

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Completed 20 July 2020

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