Amusement Accident Report - Iowa Workforce Development printable pdf download

Amusement Accident Report - Iowa Workforce Development

Division of Labor Services

Office Use Only

Date Rec.____________

Time Rec.____________

Elevator, Boiler, and Amusement Ride Bureau

1000 East Grand Avenue

Initials_______________

Des Moines, Iowa 50319-0209

Ph#: 515-281-5415 or 515-281-3418 FAX: 515-242-5076

AMUSEMENT ACCIDENT REPORT

Operator’s Name

Ride Name

Address of Incident

Operator’s Address

Ride Type

Date/Time Incident Occurred

(Thrill/Kiddie/Inflatable)

Permit #

City, State, Zip

Date Phone In/Time Phone In

Personal injuries and deaths.

An operator shall report in writing to the commissioner an accident resulting in injury to any person within 48

hours after occurrence of the incident. The report of an accident shall include this completed form, along with a duplicate copy of the report submitted to

insurance companies. The operator shall immediately report by telephone any accident in which a fatality occurs or a person suffers a fracture, concussion,

laceration or other traumatic injury requiring immediate surgical or medical care. The commissioner, after consultation with the operator and

determination, may require that the scene of such an accident be secured and not disturbed to any greater extent than necessary for removal of the deceased

or injured persons. If a ride is removed from service by the commissioner, the commissioner shall order an immediate investigation and the ride or device

shall be released for repair and operation only after complete investigation.

Describe fully how accident occurred and state what injured was doing when the accident occurred:

Are there any videotapes or photographs of the incident?

Yes

No (if yes, please mail copies)

Were safety orders issued at the last inspection?

Yes

Are repairs needed now?

Yes

No (Detail Repairs Needed)

Does Operator have a Permit

Yes