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4. Date of Accident
   Date of Accident
5. State of Kansas Number
7. Object Street Address
9. City
10. State
11. Zip
13. Boiler Type

    1. Heating Boiler Steam (steam heating boiler)
    2. Heating Boiler Water (hot water heating boiler, hot water supply boiler or potable water heater)
    3. Nuclear Boiler (nuclear boiler power plant system)
    4. Power Boiler (high temperature boiler portable power boiler)
    5. Process Steam Generator (evaporator, heat exchanger or vessel in which steam is generated by use of heat)
    6. Unfired Steam Boiler (unfired pressure vessel)
15. Boiler Use
17. Injuries/Deaths
19. Property Damage
21. Suspected Cause

    1. Burner Failure
    2. Faulty Design or Fabrication
    3. Improper Installation
    4. Improper Repair
    5. Limit Controls

    1. Low Water Condition
    2. Operator Error
    3. Poor Maintenance
    4. Safety Valve
25. Inspection Status
27. Current Certificate of Operation?

    1. Yes
    2. No
29. Inspected By
31. Inspecting Organization
35. Report Submitted By
37. Name of Authorized Inspector or Deputy Inspector
39. Company
41. Date
    Date
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