|
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; 7/31/2014 |
| 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:
Mine Safety & Health Administration
Office of Injury & Employment Information
PO Box 25367 DFC
Lakewood, CO
OFFICE: 1-303-231-5453
FAX: 1-888-231-5515
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, Office of Standards, Regulations and Variances, 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. |
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