Elevator Entrapment Report Form
Use this form to report an elevator entrapment incident and provide the key details needed for follow-up. Keep the title exactly as written.
Incident Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Role / Relationship to Incident
*
Please Select
Passenger
Building Staff
Security
Maintenance
Witness
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Elevator and Location Details
Building/Site Name
*
Exact Elevator Location
*
Elevator ID / Cab Number
Incident Information
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Number of People Trapped
*
Current Status of Occupants
*
Still Trapped
Rescued
Unknown
Brief Description of What Happened
*
Actions Taken So Far
*
Additional Assistance Needed Now?
*
Yes
No
Unknown
Submit Report
Should be Empty: