Amusement 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.

Operator Information

Operator's Name
Operator Address

Accident Information

Ride Type
Address of Incident

Additional Accident Detail

Videotape and/or Photographs of the incident?
Were safety orders issued at the last inspection?
Does the operator have a permit to operate?
Are repairs needed now?
Has the ride been secured from operation?
Has the Operator been notified?


Re-order Witness Name Witness Address Witness Phone Witness Age Weight Operations
more items

People Injured

Re-order Name Age Phone Address Email Guardian Name Guardian Phone Injury Fatal? Hospitalization Required? First Aid Weight Operations
Injury Fatal?
Hospitalization Required?
First Aid
more items


Sign above
Signed By