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AMUSEMENT DEVICE NOTIFICATION OF ACCIDENT REPORT

Page 1

Licensing Division

Elevator Inspection Division

________________

DATE:

Special Applications Unit

280 Broadway, 4th Floor

42 Broadway

New York, NY 10007

_______

______

New York, NY 10004

PAGE

An amusement device owner/operator must report any accident occurring on , within the premise of, or related to the operation of an amusement device involving injury to any person requiring the services of a

physician or damage to property or to apparatus exceeding one thousand dollars on, about, or in connection with such equipment. The accident shall be reported promptly to Department of Consumer Affairs

and the Department of Buildings. Immediately call 311 to report the accident and fax the report to Department of Buildings (212) 566-5770 and notify Department of Consumer Affairs by telephone (212)

487-7074, fax (718) 935-6516, or e-mail to accidentreports@dca.nyc.gov Do not operate or tamper with device until an inspection / investigation is conducted by the Department of Buildings Elevator

Division. Any statements taken from the amusement ride operator. Company personnel and/or witnesses must be attached to this report.

LICENSEE’S INFORMATION

Name of Amusement Company:

Address of Amusement Company:

Name of Fair / Event:

Address of Fair / Event:

Licensee Name:

DCA License Number:

Licensee’s Telephone Number:

NYC ID Number:

Serial:

Manufacturer:

INJURED PERSON’S INFORMATION

RIDE OPERATOR’S INFORMATION

Name of Injured Person:

Name of Operator:

Address:

Telephone Number:

Age:

Sex:

Telephone Number:

Age:

Sex:

ACCIDENT INFORMATION

Date of Accident :

Approximate Time of Accident:

Have you notified the Department of Buildings?

Did accident occur on device?:

Yes

Place where accident occurred:

If accident did not occur on device, where did it occur?:

Was accident a result of:

Mechanical Default

Operation Default

Patron

Other:

Name of Ride:

License Number:

Briefly Describe Injury (s):

Briefly describe how accident occurred (continue on reverse side if needed):

Describe actions taken after accident

Note: Any statements taken from ride operator, company personnel or witnesses, or statements and reports filed by the New York City Police Department,

fair/event security or Emergency Medical Services at the scene of the accident must be attached to this report.

WITNESSES

Name of Witness:

Address of Witness:

Telephone Number:

Name of Witness:

Address of Witness:

Telephone Number:

Name of Witness:

Address of Witness:

Telephone Number:

Note: Continue on reverse for additional witnesses if needed:

PENALTY FOR FALSIFICATION

Any false statement on this application is a crime punishable by a fine, imprisonment, or both. A fine for each false statement as high as $500.00, may be im-

posed by DCA. In addition, each false statement is punishable by a fine as high as $1,000.00 if prosecuted criminally.

Name of Owner /Operator/Agent (Print):

Signature:

Title:

Date:

8/09