Form EL001 "Elevator Incident Reporting Form" - Minnesota

What Is Form EL001?

This is a legal form that was released by the Minnesota Department of Labor and Industry - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2008;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form EL001 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form EL001 "Elevator Incident Reporting Form" - Minnesota

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DEPARTMENT OF
LABOR AND INDUSTRY
EMAIL FORM
PRINT
RESET
Construction Codes and Licensing/Elevator Inspections
443 Lafayette Road North
St. Paul, MN 55155-4341
Elevator Incident Reporting Form
Phone: 651-284-5071
Email: DLI.Elevator.Etrakit@State.mn.us
PRINT IN INK or TYPE
1.
Owners or managers shall use this form to report personal injury accidents or damage to equipment when they occur on, about, or
in connection with an elevator related device.
2.
Phone notification is allowed, however this form must be submitted within 1 working day of the incident.
3.
Incidents will be investigated. Investigations may be by on-site inspection, correspondence, or by telephone.
4.
The owner or manager will be notified within one working day of the investigation of any action taken by the department, and the
basis for the action. Notification will include specific details.
5.
The owner or manager will be provided with the opportunity to discuss any aspect of incident, or resultant investigation with the state
elevator inspector.
6.
Questions or concerns regarding incidents shall be directed to the elevator inspector.
7.
Pursuant to the Data Practices Act (Minnesota Statutes Chapter 13) investigation reports are private until the investigation is
complete and the file is closed. Only the state elevator inspector, the state building inspector or the commissioner may close a file.
This form is provided to assist in filing a report of accidents or damage to elevator related equipment under the jurisdiction of the
Department of Labor and Industry, Construction Codes and Licensing Division, Elevator Safety Section.
REPORT TYPE:
ACCIDENT
DAMAGED EQUIPMENT
ACCIDENT SECTION
Medical attention required? YES
NO
Have there been reports of erratic operation or malfunction on this device?
YES
NO
Briefly describe the reported accident:
DAMAGED EQUIPMENT SECTION:
Did the damage result in a threat to life or physical safety, or damage to the property structure?
YES
NO
Briefly describe the extent of the damage to the elevator related device:
ELEVATOR RELATED DEVICE IDENTIFICATION(State ID# or building device designation)
Was this report filed by phone also? YES
NO
If YES, who reported it and when?
YOUR NAME
TITLE
YOUR PHONE
SITE NAME
SITE PHONE
SITE ADDRESS
CITY
ZIP CODE
SIGNATURE
DATE
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
Office Use Only
DATE RECEIVED TIME
ELEVATOR MN ID#
RECEIVED BY
EL001 (10//08)
m
DEPARTMENT OF
LABOR AND INDUSTRY
EMAIL FORM
PRINT
RESET
Construction Codes and Licensing/Elevator Inspections
443 Lafayette Road North
St. Paul, MN 55155-4341
Elevator Incident Reporting Form
Phone: 651-284-5071
Email: DLI.Elevator.Etrakit@State.mn.us
PRINT IN INK or TYPE
1.
Owners or managers shall use this form to report personal injury accidents or damage to equipment when they occur on, about, or
in connection with an elevator related device.
2.
Phone notification is allowed, however this form must be submitted within 1 working day of the incident.
3.
Incidents will be investigated. Investigations may be by on-site inspection, correspondence, or by telephone.
4.
The owner or manager will be notified within one working day of the investigation of any action taken by the department, and the
basis for the action. Notification will include specific details.
5.
The owner or manager will be provided with the opportunity to discuss any aspect of incident, or resultant investigation with the state
elevator inspector.
6.
Questions or concerns regarding incidents shall be directed to the elevator inspector.
7.
Pursuant to the Data Practices Act (Minnesota Statutes Chapter 13) investigation reports are private until the investigation is
complete and the file is closed. Only the state elevator inspector, the state building inspector or the commissioner may close a file.
This form is provided to assist in filing a report of accidents or damage to elevator related equipment under the jurisdiction of the
Department of Labor and Industry, Construction Codes and Licensing Division, Elevator Safety Section.
REPORT TYPE:
ACCIDENT
DAMAGED EQUIPMENT
ACCIDENT SECTION
Medical attention required? YES
NO
Have there been reports of erratic operation or malfunction on this device?
YES
NO
Briefly describe the reported accident:
DAMAGED EQUIPMENT SECTION:
Did the damage result in a threat to life or physical safety, or damage to the property structure?
YES
NO
Briefly describe the extent of the damage to the elevator related device:
ELEVATOR RELATED DEVICE IDENTIFICATION(State ID# or building device designation)
Was this report filed by phone also? YES
NO
If YES, who reported it and when?
YOUR NAME
TITLE
YOUR PHONE
SITE NAME
SITE PHONE
SITE ADDRESS
CITY
ZIP CODE
SIGNATURE
DATE
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
Office Use Only
DATE RECEIVED TIME
ELEVATOR MN ID#
RECEIVED BY
EL001 (10//08)