This report is required by law (30 U.S.C. §813; 30 C.F.R. Part 50). Failure to report can result in the institution of a civil action for relief under 30 U.S.C. 9818 respecting an operator of a coal or other mine, and assessment of a civil penalty against an operator of a coal or other mine under 30 U.S.C. 9820(a). An individual who, being subject to the Federal Mine Safety and Health Act of 1977 (30 U.S.C. 9801 at seq.) knowingly makes a false statement in any report can be punished by a fine of not more than $10,000 or by imprisonment for not more than 5 years, or both, under 30 U.S.C. § 820.(f). Any individual who knowingly and willfully makes any false, fictitious, or fraudulent statements, conceals a material fact, or makes a false, fictitious, or fraudulent entry, with respect to any matter within the jurisdiction of any agency of the United States can be punished by a fine of not more than $10,000, or imprisoned for not more than 5 years, or both, under 18 U.S.C. 91001.

Form 7000-1 consists of four sheets, an original (page 1) and three copies. The original may be mailed or faxed to MSHA, Office of Injury & Employment Information. The first copy (page 2) will be mailed to the appropriate local MSHA District or Subdistrict Office. Envelopes are included with the forms for mailing to those offices. If the original forms do not show return to duty information on an injured employee, complete and mail or fax the second copy (page 3) to MSHA, Office of Injury & Employment Information (OIEI), when the employee returns to regular job at full capacity or a final disposition is made on the injury or illness.

Mail or Fax:

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

Electronically:

Form 7000-1 can also be filed electronically from http:/ /www.msha.gov/forms/elawsforms/7000-l.htm. Page 1 goes to OIEI while Page 2 will be sent to the appropriate MSHA District office.

Page 3 can be filed electronically when the employee returns to regular job at full capacity or a final disposition is made on the injury or illness.

The third copy (page 4) is to be retained at the mine for a period of five years. It is important to remember that a Form 7000-1 is required on each accident as defined in 30 CFR Part 50 whether any person was injured or not. A form is required on each individual becoming injured or ill, even when several were injured or made ill in a single occurrence. The principal officer in charge of health and safety at the mine or the supervisor of the mine area in which the accident, injury, or illness occurred shall be responsible for completing the Form 7000-1. Note: Fh·st aid cases (those for which no medical treatment was received, no time was lost, and no restriction of work, motion, or loss of consciousness occurred) need not be reported.

Detailed instructions for completing Form 7000-1 are contained in Part 50. A copy of Part 50 was sent to every active and intermittently active mine and independent mining contractor. If you do not have a copy, you may obtain one from your local MSHA Mine Safety and Health District or Subdistrict Office.

Check the report category indicating whether your operation is in the metal/nonmetal mining industry or the coal mining industry.

MSHA ID Number is the number assigned to the operation by MSHA. If you are unsure of your number assignment, contact the nearest MSHA Mine Safety and Health District or Subdistrict Office. Reports on contractor activities at mines must include an MSHA-assigned contractor ID Number as well as the 7-digit operation ID.

Show mine name and company name. Independent contractors should provide the mine name and show the contractor name under "company name. "

Section B is to be completed only when your operation has an accident that must be reported immediately to MSHA. Circle code 02 "Serious Injury" only if the injury has a reasonable potential to cause death. For additional detail on those specific kinds of accidents see Section 50.10 of Part 50. When it is necessary to complete Section B, circle the applicable accident code; give the name of the investigator (the person heading the investigating team on the accident); show the date the investigation was started; and describe briefly the steps taken to prevent a recurrence of such an accident.

Section C must be completed on each form submitted to MSHA.

Item 5. If you are reporting an occurrence at a surface mine or other surface activity, circle the code which best describes the accident location in (a). Surface Location; do not mark any codes in (b) or (c). If you are reporting an occurrence in an underground mine, circle the code which best describes the underground location in (b) Underground Location and in (c) Underground Mining Method.

Items 6, 7, and 8. Show the date and time of the occurrence and the time the shift started in which the accident/incident occurred or was observed.

Item 9. Describe fully the conditions contributing to the occurrence. Detailed descriptions of the conditions provide the basis for accident and injury analyses which are intended to assist the mining industry in preventing future occurrences. Please see Part 50 for detail on what your narrative should include.

Item 10. If equipment was involved in the occurrence, name the type of equipment, the manufacturer, and the model number of the equipment.

Item 11. If there was a witness to the occurrence, give the name of the witness.

Item 12. If the occurrence resulted in one or more injuries, report the number. A separate report must be made on each injured person.

Item 13. Show the name of the injured person. [Note: In these instructions, "injured person" means a person either injured or ill.]

Item 14. Indicate the sex of the injured person.

Item 15. Show the date of birth of the injured person.

Item 16. Show the last four digits of the injured person's Social Security Number.

Item 17. Give the regular job title of the injured person at the time he was injured.

Item 18. Check this box if the injury or illness resulted in death.

Item 19. Check this box if the injury or illness resulted in a permanent disability. A permanent disability is any injury or occupational illness other than death which results in the loss (or complete loss of use) of any member (or part of a member) of the body, or a permanent impairment of functions of the body, or which permanently and totally incapacitates the injured person from following any gainful occupation.

Item 20. Name the object or substance that directly caused the injury or illness.

Item 21.  Report the nature of injury or illness by naming the illness; or for injuries, by using common medical terms such as puncture wound, third degree burn, fracture, etc. For multiple injuries, enter the injury which was the most serious. Avoid general terms such as hurt, sore, sick, etc.

Item 22. Name the part of body with the most serious injury.

Item 23. Occupational illness is any abnormal condition or disorder, other than one resulting from an occupational injury, which falls into the following categories:

Code 21 - Occupational Skin Diseases or Disorders. Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; chrome ulcers; chemical burns or inflammations; etc.

Code 22 - Dust Diseases of the Lungs (Pneumoconioses). Examples: Silicosis, asbestosis, coal worker. s pneumoconiosis, byssinosis, and other pneumoconioses.

Code 23 - Respiratory Conditions Due to Toxic Agents. Examples: Pneumonitis, pharyngitis, rhinitis, or acute congestion due to chemicals, dusts, gases, or fumes; etc.

Code 24 - Poisoning (Systemic Effects of Toxic Materials). Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals, poisoning by carbon monoxide, hydrogen sulfide, or other gases; poisoning by benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays such as parathion, lead arsenate; poisoning by other chemicals such as formaldehyde, plastics, and resins; etc.

Code 25 - Disorders Due to Physical Agents (Other than Toxic Materials). Examples: Heatstroke, sunstroke, heat exhaustion and other effects of environmental heat; freezing, frostbite and effects of exposure to low temperatures; caisson disease; effects of ionizing radiation (isotopes, x-rays, radium); effects of nonionizing radiation (welding flash, ultraviolet rays, microwaves, sunburn); etc.

Code 26 - Disorders Associated with Repeated Trauma.

Examples: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis; Raynaud's phenomena; and other conditions due to repeated motion, vibration, or pressure.

Code 29 - All Other Occupational Illnesses. Examples: Infectious hepatitis, malignant and benign tumors, all forms of cancer, kidney diseases, food poisoning, histoplasmosis; etc.

Item 24.  Describe what the employee was doing when he or she became injured or ill.

Items 25, 26, and 27. Show the number of weeks (or years and weeks) of experience of the injured person at the job title (indicated in Item 17), at your operation, and his/her total mining experience.

Section D is to be completed in full when all return-to-duty information is available. If the information is not available within ten working days after a reportable occurrence, then the first two pages are sent to MSHA without Section D being completed; PAGE 3 is then mailed to DSHTC- with full information when the data are available. Until all the items are answered and the report sent to DSHTC-DMIS, the occurrence remains an open case.

Item 28. If the injured person was transferred or terminated as a result of the injury or illness, check the box and answer items 29, 30, and 31.

Item 29. Show the date that the injured person returned to his regular job at full capacity or was transferred or terminated. This date should indicate when the count of days away from work and/or days of restricted work activity have stopped.

Item 30. Show the number of workdays ^1/ the injured person did not report to his place of employment, i.e., number of days away from work.

Item 31. Show the number of workdays the injured person was on restricted work activity; do not include days away from work reported in Item 30.

At the bottom of the form, show the name of the person who completed the form; the date the report was prepared; and the telephone number where the person who completed the form may be reached.