EOED-DOL

Elevator Owner(Required)

Elevator Location Address(Required)

Street Address Address Line 2 City State ZIP Code

Elevator State ID#(Required)

Incident Location(Required)

Certificate Expiration Date(Required)

Elevator Owner Contact Name(Required)

First Last

Elevator Owner Phone(Required)

Elevator Owner Email(Required)

Date of Incident(Required)

Time of Incident(Required)

Elevator Company Name(Required)

Date of First Report to Office of Public Safety(Required)

Time of First Report to Office(Required)

Name of Person Filing Report (if different than Owner Contact)

First Last

Phone # (if different than Owner Contact)

How was owner notified of the incident?(Required)

Was the elevator taken out of service at the time of the incident?(Required)

Yes

Has the elevator been put back into service?(Required)

Yes

If yes, on what date was the elevator put back in service.

Name of person who authorized its reactivation?

First Last

Witness Information List

Name

Address

Phone

Incident/Victim Information

Name of Injured	Telephone Number	Sex	Date of Birth	Street Address	Was there an on-scene medical provider?	If yes, on-scene medical provider's name and telephone #	Phone	Hospitalized?	Nature of injury	Actions

There are no Entries.

Incident Summary

Name of person filing report(Required)

First Last

By entering your name above, you certify that the information contained in this report is true and accurate to the best of your knowledge and ability.

Email of person filing report(Required)

Date(Required)