Form number:

MSHA Form 7000-1

Form name:

Mine Accident, Injury and Illness Report

Description:

If an accident, injury or illness occurs at or in conjunction with activity at a mine, mine operators are required to report the circumstances of the incident to MSHA using
Form 7000-1.

OMB Control Number and Expiration Date:

1219-0007; 04/30/2011

Filing Options:

Form 7000-1, Mine Accident, Injury and Illness Report can be filed online electronically or the form fill version can be completed, printed (or printed and filled in manually) and sent to MSHA according to the instructions provided below

File online electronically
Form fill, print and mail or fax
Change online filing registration information

Filing Instructions:

Detailed Instructions for completing Form 7000-1, Mine Accident, Injury and Illness Report
Definitions of terms used in Form 7000-1, Mine Accident, Injury and Illness Report

Form 7000-1, Mine Accident, Injury and Illness Report is a four-part, color-coded form. If filing online, copies will be sent electronically to the appropriate offices.

If you are using the form fill option, make four copies of the completed form and mail or fax as follows:

Copy 1: Original (White) should be sent to:

MSHA Office of Injury and Employment Information
P.O. Box 25367
Denver, Colorado 80225

Toll-free fax: (888) 231-5515 (If sending via fax, please use black ink and do not send a copy of the same form via regular mail unless requested to do so.)

Copy 2: Return to Duty Report (Pink) should be sent to above address only after the employee has returned to full duty or been transferred or terminated. Please write Pink at the top and complete Section D - Return to Duty Information.

Note: It is not necessary to send in the Pink copy if Section D is completed on the original 7000-1.

Copy 3: should be sent to your Local MSHA District Office (Yellow)

District office contact information for coal mines
District office contact information for metal/nonmetal mines

(If sending via fax, please use black ink and do not send a copy of the same form via regular mail unless requested to do so.)

Note: Please write “Yellow” at the top of this copy

Copy 4: should be retained at the mine (or nearest mine office) for five years.

Contact Information:

Questions regarding this form should be directed to MSHA at (877) 778-6055 or MSHAhelpdesk@dol.gov

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 50.20

Burden Statement:

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This is a mandatory collection of information as required by 30 CFR 50.20. The information is used to establish injury, accident or illness files used to measure the levels of injury experience and identify those areas most in need of improvement. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Mine Safety and Health Administration, U.S. Department of Labor, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.