Minnesota Department of Labor and Industry Construction Codes and Licensing Division Elevator Inspections 443 Lafayette Road

North St. Paul, MN 55155-4341 Phone: (651) 284-5068 Fax: (651) 284-5749 www.doli.state.mn.us TTY: (651) 297-4198 1. 2. 3.

Reset

Elevator Complaints Procedure and Form
PRINT IN INK or TYPE

Any person may make a complaint. Complaints received in person or by telephone must be documented on a complaint form provided by this department. All complaints will be investigated. Investigation may be by on-site inspection, correspondence or by telephone. Assignment of investigations of complaints will be made by the supervisor of the elevator safety section. 4. The purpose of the investigation of a complaint is to resolve safety issues before someone gets hurt. Investigations will be limited to safety issues. 5. Whenever feasible the property owner or manager will be notified in advance that an investigation regarding a safety complaint has been initiated and, where on-site inspection is required, the owner or manager will be invited to accompany the inspector on the investigation. Where notification is not immediately possible, the owner/manager will be notified within one working day of the investigation of the action taken by the department and the basis for the action. Notification will include specific details. 6. The owner or manager will be provided with the opportunity to discuss any aspect of a complaint, or the resultant investigation with the state elevator inspector. 7. Questions or concerns regarding complaints should be referred to the state elevator inspector. 8. 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. 9. Private means that the person or firm who is the subject of the complaint may see the file, but others may not. Complaints are confidential and may not be given to the subject of the complaint. 10. Those filing complaints do not have to agree to reveal to others their identity, but they should be notified that if the matter goes to court, their names may become known to all others. This form is provided for the assistance of any person who wishes to file a complaint regarding the safety of any equipment under the jurisdiction of the Department of Labor and Industry, Construction Codes and Licensing Division, Elevator Safety Section. The undersigned believes that a violation of law exists, or has occurred, which may be a safety or health hazard, or may involve the application for or issuance of licenses or permits regulated by the Department of Labor and Industry. YES NO

DOES THE HAZARD PRESENT AN IMMEDIATE THREAT TO LIFE OR PHYSICAL SAFETY? If YES, explain:

LOCATION OF ALLEGED VIOLATION: NAME OF BUSINESS ADDRESS TYPE OF BUSINESS CITY NAME (Person in charge at the site of the alleged complaint)

PHONE STATE PHONE ZIP CODE

Briefly describe the alleged safety hazard, including the approximate number of people exposed to the alleged violation. (Add pages if needed).

To your knowledge, has this alleged violation been reported to, or investigated by another governmental agency? YES NO If YES, name of the agency If YES, approximate date of reporting or investigation by the other governmental agency: Is this complaint alleging a similar concern, being filed with any other governmental agency? YES NO NOTE: The Department of Labor and Industry does not release the name of complainant while an alleged If YES, name of the agency
complaint is under investigation. However, if the alleged complaint requires resolution by way of an Administrative Hearing, the due process provisions of the Administrative Procedures Act (Minn. Statute, Chapter 14, or related Department Rules) which may require the name(s) of the person(s) signing the complaint to be revealed.

NAME OF COMPLAINANT ADDRESS SIGNATURE OF COMPLAINANT CITY

PHONE STATE DATE ZIP CODE

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
EL001 (2//07)

ELEVATOR MN ID#

RECEIVED BY