Boiler & Pressure Vessel Accident Report Form

Use this form to report a boiler or pressure vessel explosion.

File this form if a boiler or pressure vessel explodes or a malfunction causes an acute illness or injury that needs professional medical care, or a disability that lasts more than one day. Report by calling 515-725-5609 or 515-725-5610. An incident that occurs during Division of Labor office hours must be reported by close of business on the day of the incident. An incident that occurs when the Division of Labor is closed must be reported by close of business on the next Division of Labor business day.

Removal of damaged parts or use of the object is prohibited by Iowa Administrative Code.

Owner Information

Owner's Name

Address Information

Owner's Address
Equipment Location

Accident Information

Are there videotapes or photographs of the incident?
Were safety orders issued at the last inspection?
Does boiler or pressure vessel have an operating certificate?
Are repairs needed now?
Has boiler or pressure vessel been secured from operation?
Have the local authorities been notified?

Witness Information

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

Injury Information

Re-order Injured Name Injured Address Injured Age Injured Phone Injured Email Parent/Guardian Name Fatal Hospitalization First Aid Injury Details Weight Operations
more items


I certify that the information on this form and the attachments (if any) is true and accurate to the best of my knowledge.
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