TDLR Elevator Incident Report

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TDLR Elevator Incident Report Powered By Docstoc
					                         TEXAS DEPARTMENT OF LICENSING AND REGULATION
                                          P. O. BOX 12157, AUSTIN, TEXAS 78711
                          E.O. THOMPSON BUILDING, 920 COLORADO, AUSTIN, TEXAS 78701
                                       1-800-803-9202 (512) 539-5725 FAX: (512) 539-5729
                               www.license.state.tx.us - elevators.escalators@license.state.tx.us

                                 TDLR Elevator Incident Report
Date:___________________________ Time:___________________________ ELBI#______________
Building name:________________________________________________________________________
Building address:______________________________________________________________________
**E-mail address:_____________________________________________________________________
Contact on site:__________________________________________Phone #:______________________
Name of person making report:__________________________________________________________
Nature of injury:______________________________________________________________________
Name of injured:_____________________________________________________ Age:_____________
Description of incident:_________________________________________________________________
_____________________________________________________________________________________
Type of equipment:_________________________________________ Decal #:___________________
Manufacturer of Equipment:____________________________________________________________
Capacity of elevator:_______________________ Speed of elevator:____________________________
Type of door:_________________________________________________________________________
Type of door protection:________________________________________________________________
Door torque:___________________________ Kinetic energy:_________________________________
Door time to open:________________________ Door time to close:____________________________
Nudging torque:_______________________________________________________________________
Door operation comments(optional):________________________________________________________
Elevator operation comments(optional):_____________________________________________________
Comments:___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
** The Department will add your address to the Elevator email notification list, which automatically provides information from the Department on
matters affecting Elevators. Your email address is confidential pursuant to the Texas Public Information Act and the Department will not share it with
the public. See additional information at the following link: http://www.license.state.tx.us/newsletters/TDLRnotificationLists.asp


TDLR a016ELE 07/09