Mine Accident, Injury & Illness Report and Quarterly Mine Employment and Coal Production Report

MSHA - Forms and Online Filings - Form 7000-1 - Mine Accident, Injury and Illness Report

UNITED STATES
DEPARTMENT OF LABOR

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Mine Safety and Health Administration - MSHA                                              
     - Protecting Miners' Safety and Health Since 1978

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 1219-0007; 7/31/2014
Expiration Date:
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 fourpart, 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 PEIR-Office of Injury and Employment
Information
P.O. Box 25367
Denver, Colorado 80225-0367
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

http://www.msha.gov/forms/elawsforms/7000-1.htm[4/22/2014 3:36:06 PM]

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MSHA - Forms and Online Filings - Form 7000-1 - Mine Accident, Injury and Illness Report

(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.

Complete and File Form Online
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FAQs |  Freedom of Information Act |  Privacy & Security Statement |  Disclaimers |  Customer Survey |  Online Filing Help Desk  |  Contact Us
U.S. Department of Labor | Mine Safety and Health Administration (MSHA) | 1100 Wilson Boulevard, 21st Floor | Arlington, VA 22209-3939
www.msha.gov | Telephone: (202) 693-9400

http://www.msha.gov/forms/elawsforms/7000-1.htm[4/22/2014 3:36:06 PM]