Appendix C. MSHA Form 7000-1 (Mine Accident, Injury and Illness Report)

Mine Accident, Injury and Illness Report

U.S. Department of Labor
Mine Safety and Health Administration
• Section A - Identification Data

Approved For Use Through 04/30/2008 OMB Number 1219-0007
• Check here if report
pertains to contractor
Coal Mining
Metal/Nonmetal Mining
Company Name

Report Catagory

Contractor ID

MSHA ID Number

Mine Name

• Section B - Complete for Each Reportable Accident Immediately Reported to MSHA
1. Accident Code (circle applicable code - see instructions)
04 - Inundation

Day

12 - Offsite injury

11 - Hoisting

3. Date Investigation Started
Month

08 - Roof Fall

07 - Explosives

06 - Mine Fire

10 - Impounding Dam

09 - Outburst
2. Name of Investigator

03 - Entrapment

02 - Serious Injury

01 - Death

05 - Gas or Dust Ignition

4. Steps Taken to Prevent Recurrence of Accident

Year

• Section C - Complete for Each Reportable Accident, Injury or Illness
5. Circle the Codes Which Best Describe Where Accident/Injury/Illness Occurred (see instructions)
(a) Surface Location:

02 Surface at Underground Mine
06 Dredge Mining

05 Culm Bank/Refuse Pile

(b) Underground Location:

(c) Underground Mining Method:
Day

02 Shortwall

01 Longwall

03 Face

Year

04

06 Other

05 Underground Shop/Office

Intersection

05 Continuous Mining

03 Conventional Stoping

06 Hand

07 Caving

08 Other

8. Time Shift Started • am
• pm

7. Time of Accident • am
• pm

6. Date of Accident
Month

02 Slope/Inclined Shaft

01 Vertical Shaft

04 Surface Auger Operation
99 Office Facilities

03 Strip/Open Pit Mine
30 Mill, Preparation Plant, etc.
17 Independent Shops (with own MSHA ID)
12 Other Surface Mining

7
8

9. Describe Fully the Conditions Contributing to the Accident/Injury/Illness, and Quantify the Damage or Impairment

10. Equipment Involved

Model Number

Manufacturer

Type

11. Name of Witness to Accident/Injury/Illness

10
MAN

12. Number of Reportable Injuries or Illnesses
Resulting from This Occurrence

13. Name of Injured/Ill Employee

15. Date of Birth

14. Sex
• Male
• Female
17. Regular Job Title

16. Last Four Digits of Social
Security Number

• 18. Check if this
Injury/Illness
resulted in death.
21. Nature of Injury or Illness

20. What Directly Inflicted Injury or Illness?

12
14
• 19. Check if Injury/Illness 16
resulted in permanent disability 17
(include amputation, loss of use, 18
& permanent total disability.
19
Month

D ay

Year

20
21

23. Occupational llness (circle applicable code - see instructions)

22. Part of Body Injured
or Affected

22 Dust Diseases of the Lungs

23 Respiratory Conditions (toxic agents)

25 Disorders (physical agents)

24. Employee’s Work Activity When
Injury or illness Occurred

26 Disorders (repeated trauma)

Years

Experience

Weeks

25. Experience in This Job Title

Answer

29. Date Returned to Regular Job at
Full Capacity (or item 28)
Month

Day

Year

30

&

31

when

30. Number of
Days Away from
W ork (if none,
enter 0)

Person Completing Form (name)

Title

Date This Report Prepared (month, Day, year)

Area Code and Telephone Number

MSHA Form 7000-1, Feb 00 (revised)

Reset Form

For Official Use Only
Accident Type

27. Total Mining Experience
• 28. Permanently Transferred or
Terminated (if checked,
complete items 29,30, &31)

29 Other

Degree

26. Experience at This Mine

• Section D - Return to Duty Information

21 Occupational Skin Diseases
24 Poisoning (toxic Materials)

case

is

closed

31. Number of Days
Restricted Work
Activity (if none,
enter 0)

Accident Class
Scheduled Charge
Keyword

22
24