The Amusement Ride Incident Report is the form the Mississippi Department of Revenue (DOR) prints for reporting a minor injury or illness, a serious injury or illness, or a death involving an amusement ride. It is a ride-specific form, not a general-purpose incident report. The person reporting for the ride's owner or operator checks the severity box, identifies the ride and the injured party, and describes what happened, including any first aid given. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by DOR on its website.
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What is Amusement Ride Incident Report – Mississippi?
The Amusement Ride Incident Report is the Mississippi Department of Revenue form used to report a minor injury or illness, a serious injury or illness, or a death involving an amusement ride, with details of the owner or operator and the injured party.
The form opens with a Check One line offering three choices: Minor Injury / Illness, Serious Injury / Illness and Death. The choice matters because the form ties each category to a different reporting time limit. Below it, the Owner / Operator Information block records who is reporting, their job title, a date and time, the ride manufacturer's name and the ride's serial number. The Injured Party Information block records the name of the party involved, two address lines, a telephone number and the age.
The centre of the page is the INCIDENT DESCRIPTION, where the form asks you to include any first aid treatment given. After the signature and date, the form asks whether a police report was filed and leaves lines for the reporting officer, telephone and precinct. A Department Use Only block records whether an investigation is warranted and is not for the person reporting.
The header of the form lists the Department's address in Clinton, Mississippi, its telephone and fax numbers, its email and its website. A Page ___ of ___ line lets a longer report be numbered.
Who needs to file Amusement Ride Incident Report – Mississippi?
The form is completed by the person reporting an incident for the owner or operator of an amusement ride. Its Owner / Operator Information block asks for the name and job title of whoever is reporting, so the person filling it out need not be the owner, but the report is made on the owner's or operator's behalf and must be signed.
It applies to three kinds of events, each a box under Check One:
- a minor injury or illness;
- a serious injury or illness;
- a death.
The form states that serious injury or illness and death must be communicated to the Mississippi Department of Revenue by telephone and in writing, and that minor injury or illness must also be communicated, each within its own time limit (see the deadline section).
The injured party does not complete the form. Their details (name, address, telephone and age) are entered in the Injured Party Information block by the person reporting. If the police were involved, the same person records that on the form, including the reporting officer's name, telephone and precinct.
When to file Amusement Ride Incident Report – Mississippi
The reporting clock is set by the type of incident, and the form prints the limits at the top. A serious injury or illness, or a death, must be communicated to the Department of Revenue within (2) hours by telephone and within (24) hours by written form. A minor injury or illness must be communicated within (72) hours.
The written form for a serious injury, illness or death is therefore due within 24 hours, and the telephone call is a separate, earlier step. The form prints no other deadline, renewal period or validity date.
How to fill out Amusement Ride Incident Report – Mississippi
Check the incident category
On the Check One line, mark Minor Injury / Illness, Serious Injury / Illness or Death. The category decides the reporting time limit printed at the top of the form.
Number the pages
Fill in Page ___ of ___ at the top of the incident report so the pages of a longer report stay together.
Enter the reporter's details
In Owner / Operator Information, enter Reported By, Job Title, Date and Time.
Identify the ride
Still in Owner / Operator Information, enter the Ride Manufacturer Name and the Serial Number of the ride involved.
Enter the injured party's details
In Injured Party Information, enter Name of Party Involved, Address, Address (2), Telephone and Age.
Describe the incident
In INCIDENT DESCRIPTION, explain what happened and include any first aid treatment given, as the form instructs.
Sign and date the report
Enter your signature and the date on the Signature and Date lines below the description.
Record any police report
Mark Police Report Filed Yes or No. If a report was filed, enter the Reporting Officer, Telephone and Precinct.
Leave the Department block blank
Do not complete Department Use Only, which holds the Investigation Warranted Yes/No boxes and is for the Department.
Review and download the PDF
Check the category, times and ride details, then download or print the completed PDF from FillingPDF and send it as described under How to submit.
How to submit Amusement Ride Incident Report – Mississippi
The form names the Mississippi Department of Revenue as the recipient and prints its contact details in the header:
- Telephone: 601-923-7700. The form requires serious injury or illness and death to be communicated by telephone within 2 hours.
- Mail address: 500 Clinton Center Drive, Clinton, MS 39056.
- Fax: 601-923-7188.
- Email: [email protected].
- Website: www.dor.ms.gov.
The form does not say which of these the written report must use, so confirm with the Department by telephone before you send it. Leave the Department Use Only block blank, and sign and date the report before sending. FillingPDF lets you fill out and download the PDF; submission follows the Department's channels above.
Common mistakes to avoid
- Sending only the written form for a serious injury, illness or death; the form also requires a telephone report to the Department within (2) hours.
- Submitting the written report for a serious injury, illness or death after the (24)-hour limit, or a minor injury or illness report after the (72)-hour limit.
- Leaving the Check One line unmarked, or picking Minor Injury / Illness when the incident is serious, since the reporting time depends on the category.
- Writing an incident description without any first aid treatment given; the form asks you to include it.
- Leaving out the ride manufacturer name or the serial number in the Owner / Operator Information block.
- Leaving the Police Report Filed Yes/No boxes blank, or filing a report with the officer's name, telephone and precinct missing when a report was made.
- Sending the form unsigned or without the date beside the signature.
- Completing the Department Use Only block, including Investigation Warranted, which is reserved for the Department.
Frequently asked questions
What is the Amusement Ride Incident Report?
It is a Mississippi Department of Revenue form for reporting a minor injury or illness, a serious injury or illness, or a death involving an amusement ride. It records the owner or operator, the ride, the injured party and a description of the incident.
How fast must an amusement ride injury be reported in Mississippi?
The form states that a serious injury or illness, or a death, must be reported to the Department of Revenue within (2) hours by telephone and (24) hours by written form. A minor injury or illness must be communicated within (72) hours.
Do I have to report a minor injury on this form?
The form has a Minor Injury / Illness box and states that minor injury or illness must be communicated to the Department of Revenue within (72) hours. It does not set a telephone requirement for minor incidents.
Where do I send the Amusement Ride Incident Report?
The form prints the Department's address, 500 Clinton Center Drive, Clinton, MS 39056, along with fax 601-923-7188, email [email protected] and telephone 601-923-7700. It does not name one channel for the written report, so confirm with the Department.
Can I fill out the incident report online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service: it does not send the report to the Department of Revenue, so you still submit it through the Department's contact channels and call within the stated time.
What should the incident description include?
The form asks you to describe the incident and to include any first aid treatment given. It prints no other required wording, so give the facts of what happened alongside the injured party's name, age and contact details.
What is the Department Use Only section on this form?
It is the block at the bottom right where the Department records whether an investigation is warranted (Yes or No). The person reporting does not complete it.
Is a police report required with the Amusement Ride Incident Report?
The form asks whether a police report was filed (Yes or No) and, if so, for the reporting officer's name, telephone and precinct. It does not say that a police report is required or that one must be attached.
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