Safety Complaint Form

National Work Zone Awareness Week
April 15-19, 2024

Struck-by incidents are the 2nd leading cause of death among construction workers, and the leading cause of nonfatal injuries in the construction industry.

Workers Memorial Day
April 29th, 2024 @ 11 AM
State Capitol, West Terrace

This is a day to honor and remember Iowans who have died in the past year in Iowa's workplaces and serving in our Military.

April is National
Safe Digging Month

A reminder to always contact 811 before you dig!

National Small Business Week
April 28-May 4, 2024

This is a great opportunity to schedule your no-cost on-site consultation visit from IA OSHA.

Iowa OSHA is 50!
50 Years of Workplace Safety and Health

Iowa OSHA had its initial approval on
July 20, 1973,

had its State Plan certification on September 14, 1976,

and its final approval on July 2, 1985

Instructions:

This form is for reporting a dangerous condition involving an amusement ride, boiler, elevator, pressure vessel, escalator, or related equipment located in Iowa. Owners and operators are required to report an incident such as an injury, fire, or explosion using a separate report form.

You may also download the form here.

The form can also be submitted via fax to 515-242-5076, or the form can be mailed to:

Division of Labor
150 Des Moines Street
Des Moines, IA 50309-1836

Complaint Details

Type of equipment?

Amusement Ride (optional)

Boiler (optional)

Elevator & Conveyance (optional)

Pressure Vessel (optional)

Other… (optional)

What is the safety complaint you are reporting?

Owner Name

Owner's name?

First

Last

Equipment Location

Location where the equipment is located?

Address

Address 2 (optional)

City/Town

State/Province (optional)

ZIP/Postal Code

Contact Information

First (optional)

Last (optional)

Address (optional)

Address 2 (optional)

City/Town (optional)

State/Province (optional)

ZIP/Postal Code (optional)

Your phone?

Your phone?
	Your phone? (optional)	Item weight (optional)

more items

Your email?

Signature

I certify the information I am submitting to the Iowa Divison of Labor is to the best of my knowledge, true, accurate and correct. (optional)

Signature

Sign above

Signed By

Title

First (optional)

Middle (optional)

Last (optional)

Suffix (optional)

Degree (optional)

Signature Date

National Work Zone Awareness Week
April 15-19, 2024

Struck-by incidents are the 2nd leading cause of death among construction workers, and the leading cause of nonfatal injuries in the construction industry.

April is National
Safe Digging Month

A reminder to always contact 811 before you dig!

National Small Business Week
April 28-May 4, 2024

This is a great opportunity to schedule your no-cost on-site consultation visit from IA OSHA.