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Injured.add .saveable (Office of the Chief Information Officer)

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BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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People Injured
1. Name
Age
Phone number
Address
City
State
Zip
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
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
If minor, parent/guardian name
Phone number
Injuries: Fatal? Yes No Require hospitalization? Yes No Require first aid? Yes No
Nature of injury:
08.14.2017
600-007
Page 2
Witnesses
Address
Phone number
Age
Address
Phone number
Age
Address
Phone number
Age
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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Completed 13 August 2020

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