Elevator Accident Report Form - New Hampshire Department Of Labor

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF LABOR
PO BOX 2076
CONCORD, NH 03302-2076
Tel: 603-271-2585
James W. Craig
Fax: 603-271-2668
Commissioner of Labor
Kathryn J. Barger
Deputy Labor Commissioner
ELEVATOR ACCIDENT REPORT
NHE#:______________
RSA 157-B:15 Notice of Accidents. The owner shall report every elevator and accessibility lift accident, whether or not it results in injury to a person or
damage to the equipment, to the Commissioner within 48 hours after its occurrence. The inspection certificate for the involved elevator or accessibility lift
may be suspended if a qualified inspector inspects the elevator or accessibility lift and finds it to be unacceptable. An owner who willfully refuses or
neglects to make such a report shall be fined not more than $25.
Name of injured:_________________________________________________________________________________________
First Name
Middle Name
Last Name
Address:________________________________________________________________________________________________
City
State
Zip
Tel Number:_______________________________Male___________Female_________________________________________
Date of Injury________________Day of Week________________Hour of Day_______________________________________
Date Accident Reported to Owner/Lessee:_____________________________________________________________________
Owner/Lessee:__________________________________________Tel. No.__________________________________________
Office Address:__________________________________________________________________________________________
City
State
Zip
Location of Bldg/Place Accident Occurred:____________________________________________________________________
__________________________________________________________Tel No:_______________________________________
Was there any damage to equipment?:__________Please Explain:__________________________________________________
Was an elevator inspector/mechanic notified? __________________________________________________________________
If so, name and number of person notified:_____________________________________________________________________
Time and date of notification:_______________________________________________________________________________
Describe fully how accident occurred and state what injured was doing when accident occurred: ________________________
______________________________________________________________________________________________________
Name and Address of Witness:______________________________________________________________________________
Nature and Location of Injury:______________________________________________________________________________
Was accident fatal?:________________________________Non Fatal:______________________________________________
Date of this Report:__________________________Date of Last Inspection:_________________________________________
Was Certificate Issued?:___________________________________________________________________________________
By:____________________________________________________________________________________________________
NH State Elevator Inspector
Inspector Number
Rev 04/22/2014

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