Elevator, Boiler, and Amusement Ride Bureau

6200 Park Ave., Ste. 100 Des Moines, Iowa 50321

Safety Complaint

This form is for reporting a dangerous condition involving an amusement ride, boiler, elevator, pressure vessel, escalator, or related equipment located in Iowa. Owners and operators are required to report an incident such as an injury, fire, or explosion using a separate accident report form.

Complaint Details

What is the type of equipment?

Indicate the type of other equipment:

Describe the safety complaint you are reporting.

Owner Name

Owner's First Name

Owner's Last Name

Equipment Location

Address 1

Address 2

City

State

Zip Code

Contact Information

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone Number

Email

Certification Information

I certify that the information I am submitting to the Iowa Department of Inspections, Appeals, and Licensing is to the best of my knowledge, true, accurate and correct.

First Name

Last Name

Date Form Was Completed

Date Picker