Accident Report

What type of equipment was involved in the accident?

Amusement Ride Accident Report

The operator shall immediately report by phone a fatality or an accident that requires medical care more than first aid. An operator shall report in writing to the Labor Commissioner an accident resulting in injury within 48 hours after occurrence of the incident. The report of an accident shall include this completed form and a copy of the report submitted to insurance companies. The Labor Commissioner may require that the scene of an accident be secured and not disturbed more than necessary for removal of deceased or injured persons. If covered equipment is removed from service by the Labor Commissioner, the Labor Commissioner shall order an immediate investigation and the covered equipment shall be released for repair and operation only after a complete investigation.

The covered equipment may not be returned to service until it successfully passed a complete inspection.

Boiler and Pressure Vessel Accident Report

Use this form to report a boiler or pressure vessel explosion.File this form if a boiler or pressure vessel explodes or a malfunction causes an acute illness or injury that needs professional medical care, or a disability that lasts more than one day. Report by calling 515-669-8945 or 515-725-2050. An incident that occurs during DIAL office hours must be reported by close of business on the day of the incident. An incident that occurs when DIAL is closed must be reported by close of business on the next DIAL business day.Removal of damaged parts or use of the object is prohibited by Iowa Administrative Code.

Elevator and Conveyance Accident Report

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 a 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.

Operator Information

Business Name

Operator First Name

Operator Last Name

Operator Phone Number

Operator Email

Is the operator's address different than the business' address?

Yes

Operator Address

Operator Address 2 (if needed)

Operator City

Operator State

Operator Zip Code

Owner First Name

Owner Last Name

Owner Phone Number

Owner's Email Address

Owner Street Address

Owner Street Address 2

Owner City

Owner State

Owner Zip Code

Accident Information

Date and Time of Accident

Accident Description

Type of conveyance

Other Conveyance

Ride Name

Ride Type

Permit Number

Owner's ID (example: Lobby South Car 1, Car 3 North, etc.)

State ID Number

Most Recent Annual State Sticker Number

Manufacturer

Business Address

Accident Building Address

Business Address 2 (if needed)

Accident Building Address 2 (if needed)

Business City

Accident Building City

Business State

Accident Building State

Business Zip Code

Accident Building Zip Code

Witness Information

Name, Address, Phone Number and Age of Each Witness

Information About People Injured (Please enter injured parties' name, age, phone, address, email, and guardian name and phone. Indicate if the injury was fatal, and if hospitalization and/or first aid was required.)

Upload Attachment(s) - reports, photos, etc.

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Certification Information

I certify that the information on this form and attachments (if any) is true and accurate to the best of my knowledge.

Signer First Name

Signer Last Name

Signer Phone Number

Signer Email

Company or Firm Name

State of Iowa