Incident Date
(Required)
MM slash DD slash YYYY
Submitter's Name
(Required)
First
Last
Submitter's Email Address
(Required)
State Elevator ID #
(Required)
Found on the certificate in or around the elevator.
Fire Department Incident #
(Required)
Location of Incident
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Elevator Emergency: (Please explain the nature of emergency)
(Required)
Example: Elevator Extrication, Fire, Is the car between floors, etc.
Did Phase 1 work?
(Required)
Yes
No
N/A
Did Phase 2 work?
(Required)
Yes
No
N/A
Was Lock Out/Tag Out performed?
(Required)
Yes
No
Is it known if the elevator(s) is/are served by an emergency or stand by power source?
(Required)
Yes
No
Please provide a description below.
Please explain which type and where located.
(Required)
Example: Generator located on the roof, Secondary power feed, No back up power source, etc.