Fillable Form 1.: Mine Accident, Injury and Illness Report (Mine Safety and Health Administration)

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Form 1.: Mine Accident, Injury and Illness Report (Mine Safety and Health Administration)

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Mine Accident, Injury and Illness Report
Approved For Use Through 1/31/2021 OMB No. 1219-0007
Section A - Identification Data
MSHA ID number
Contractor ID
Report Category
Check her
e if report
Metal/Nonmetal Mining
Coal Mining
pertains to contractor
Mine name Company Name
Section B - Complete for Each Reportable Accident Immediately Reported to MSHA
1.
Accident Code (check applicable code - see instructions)
01 - Death
02 - Serious Injury
05 - Gas or Dust Ignition
2.
Name of investigator
3.
Date investigation started
4.
Steps taken to prevent recurrence of accident
month
day
year
Section C - Complete for Each Reportable Accident, Injury
or Illness
5.
Check the codes which best describe where accident/injury/illness occurred (see instructions)
(a) Surface Location:
03 - Strip/Open Pit Mine
04- Surface Auger Operation
30 - Mill, Preparation Plant, etc.
17 - Independent Shops (with own MSHA ID)
99 - Office Facilities
02 - Slope/Inclined Shaft
04 - Intersection
05 - Underground Shop/Office
08 - Other
6. Date of accident 7. Time of accident am 8. Time shift started am
pm pm
month
day
year
9.
Describe fully the conditions contributing
to the accident/injury/illness, and quantify the damage or impairment
10.
Equipment involved Type Manufacturer
Model number
11. Name of witness to accident/injury/illness 12. Number of reportable injuries or illnesses
resulting from this occurrence
13.
Name of injured/ill employee
14. Sex
male
15.
Date of birth
female
month
day
year
16.
Last four digits of
17. Regular job title 18. Check if this injury/
19.
Check if injury/illness resulted
Social Security number
illness resulted in death
in permanent disability (include
amputation, loss of use &
permanent total disability)
20. What directly inflicted injury or illness? 21. Nature of injury or illness
22. Part of body injured or affected 23.
24. Employee’s work activity
Experience
Years
Weeks
when injury or illness occurred
25.
Experience in this job title
26.
Experience at this mine
27.
Total mining experience
Section D - Return to Duty Information
Answer 30 & 31 when case is closed
29.
Date returned to
regular job at full
capacity (or item 28)
30.
Number of days
away from work
(if none enter 0)
28. Permanently transferred or
terminated (if checked, complete
items 29, 30, and 31)
31.
Number of days
restricted work
activity (if none, e
n
ter
0
)
month
day
year
Person completing form (name)
Title
Date this report prepared (month, day, year)
Area code and phone number
MSHA Form 7000-1, October 16 (revised)
7
8
10
Man
12
14
17
18
20
21
22
24
16
19
04 - Inundation
11 - Hoisting
10 - Impounding Dam
09 - Outburst
03 - Entrapment
06 - Mine Fire
07 - Explosives
02 - Surface at Underground Mine
06 - Dredge Mining
01 - Vertical Shaft
03 - Face
06 - Other
(c) Underground Mining Method:
01 - Longwall
02 - Shortwall
03 - Conventional Stoping
05 - Continuous Mining
06 - Hand
07 - Caving
Occupational illness (check applicable code - see instructions)
21 - Occupational Skin Diseases
22 - Dust Diseases of the Lungs
24 - Poisoning (Toxic Materials)
25 - Disorders (Physical Agents)
23 - Respiratory Conditions (Toxic Agents)
29 - Other
12 - Offsite Injury
12 - Other Surface Mining
26 - Disorders (Repeated Trauma)
08 - Roof Fall
(b) Underground Location:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
05 - Culm Bank/Refuse Pile
For official use only
Degree
Accident Type
Accident Class
Scheduled Charge
Keyword
Section 50.20 of Part 50, Title 30, Code of Federal Regulations,
requires a report to be prepared and filed with MSHA of each acci-
dent, occupational injury, or occupational illness occurring at your
operation. The requirement includes all accidents, injuries, and ill-
nesses as defined in Part 50 whether your employees or a contrac-
tor's employees are involved. A Form 7000-1 shall be completed
and mailed within ten working days after an accident or occupa-
tional injury occurs, or an occupational illness is diagnosed.
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. §818 respecting an operator of a coal
or other mine, and assessment of a civil penalty against an oper-
ator of a coal or other mine under 30 U.S.C. §820(a). An individ-
ual who, being subject to the Federal Mine Safety and Health
Act of 1977 (30 U.S.C. §801 at seq.) knowingly makes a false
state-ment 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 will-fully makes any false, fictitious, or fraudulent statements,
con-ceals 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. §1001.
REPORTING INSTRUCTIONS
Form 7000-1 consists of four sheets, an original (page 1) and
three copies. The original will be mailed to MSHA, Office of Injury
and Employment Information. The first copy (page 2) will be
mailed to the appropriate local MSHA District Office. If the
mailed forms do not show return to duty information on an injured
employee, complete and mail the second copy (page 3) to
MSHA, Office of Injury and Employment Information, 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 sin-
gle occurrence. The principal officer in charge of health and safe-
ty at the mine or the supervisor of the mine area in which the
accident, injury, or illness occurred shall complete or review the
Form 7000-1. Note: First 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.
SPECIFIC INSTRUCTIONS
Detailed instructions for completing Form 7000-1 are contained in
Part 50. A copy of Part 50 was sent to every active and intermit-
tently 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
Field Office.
Section A- IDENTIFICATION DATA
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 Field 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 show the contractor name under "company name. "
Section B- COMPLETE FOR EACH ACCIDENT IMMEDIATELY
REPORTABLE TO MSHA
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 poten-
tial 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 mine 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- COMPLETE FOR EACH REPORTABLE ACCIDENT,
INJURY, OR ILLNESS
Section C must be completed on each form submitted to MSHA.
I
t
e
m 5. If you are reporting an occurrence at a surface mine or
other surface activity, circle the code which best describes the acci-
dent 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 (indicate AM/PM) which the accident/
incident occurred or was observed.
Item 9. Describe fully the conditions contributing to the occur-
rence. 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 per-
manent disability. A permanent disability is any injury or occupa-
tional illness other than death which results in the loss (or com-
plete 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.
MINE ACCIDENT, INJURY, AND ILLNESS REPORT
MSHA FORM 7000-1
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 ill-
ness; 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 gener-
al terms such as hurt, sore, sick, etc.
Item 22. Name the part of body with the most serious injury.
Item 23. Occupational Illness: Circle the code from the list below
which most accurately describes the illness. These are typical
examples and are not to be considered the complete listing of the
types of illnesses and disorders that should be included under
each category.
Code 21 - Occupational Skin Diseases or Disor
ders.
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 pneumo-
coniosis 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 Ef
fects of Toxic Materials).
Examples: Poisoning by lead, mercury, cadmium, arse-
nic, or other metals, poisoning by carbon monoxide, hy-
drogen sulfide, or other gases; poisoning by benzol, car-
bon 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 temper-
atures; caisson disease; effects of ionizing radiation,
(non-medical non-therapeutic 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, teno-
synovitis, and bursitis; Raynaud's phenomena; and other
c
onditions 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.
Se
ction D - RETURN TO DUTY INFORMA
TION
Section D
is to be completed in full when all return-to-duty infor-
mation 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 OIEI- with full information when the
data is available. Until all the items are answered and the
report is sent to OIEI, the occurrence remains an open case.
Item 28. If the injured person was transfer
red 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/
her 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/her 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.
1/ Note: The number of lost workdays should not include the day
of injury or onset of illness, or any days on which the employee
was not previously scheduled to work even though able to work,
such as holidays or plant closures
Diagnosis of an "occupational illness or
disease" under Part 50 does not
automatically mean a disability or
impairment for which the miner is
eligible for compensation, nor does the
Agency intend for an operator's
compliance with Part 50 to be equated
with an admission of liability for the
reported illness or disease. If a chest x-
ray for a miner with a history of
exposure to silica or other
pneumoconiosis causing dusts is rated at
1/0 or above, utilizing the International
Labor Office (ILO) classification system,
it is MSHA's policy that such a finding is,
for Part 50 reporting, a diagnosis of an
occuaptional illness, in the nature of
silicosis or other pneumoconiosis and,
consequently, reportable to MSHA.
(1 ) "Coal or other mine" means (a) an area of land from which
minerals are extracted in nonliquid form or, if in liquid form, are
extracted with workers underground, (b) private ways and roads
appurtenant to such area, and (c) lands, excavations, under-
ground passageways, shafts, slopes, tunnels and workings,
structures, facilities, equipment, machines, tools, or other proper-
ty including impoundments, retention dams, and tailings ponds,
on the surface or underground, used in, or to be used in, or
resulting from, the work of extracting such minerals from their
natural deposits in nonliquid form, or if in liquid form, with workers
underground, or used in, or to be used in, the milling of such min-
erals, or the work of preparing coal or other minerals, and
includes custom coal preparation facilities. In making a determi-
nation of what constitutes mineral milling for purposes of this Act,
the Secretary shall give due consideration to the convenience of
administration resulting from the delegation to one Assistant
Secretary of all authority with respect to the health and safety of
miners employed at one physical establishment.
(2) "Operator" means any owner, lessee, or other person
who operates, controls, or supervises a coal or other mine or any
designated independent contractor performing services or con-
struction at such mine.
(3) "Occupational injury" means any injury to a worker
which occurs at a mine for which medical treatment is adminis-
tered, or which results in death, loss of consciousness, inability to
perform ail job duties on any day after an injury, or transfer to
another job.
(4) "Occupational illness" means an illness or disease of a
worker which may have resulted from work at a mine or for
which an award of compensation is made.
(5) "Medical treatment" means treatment, other than first
aid, administered by a physician or by a registered medical pro-
fessional acting under the orders of a physician.
DIFFERENCES BETWEEN
MEDICAL TREATMENT AND FIRST AID
Medical treatment includes, but is not limited to, the suturing of
any wound, treatment of fractures, application of a cast or other
professional means of immobilizing an injured part of the body,
treatment of infection arising out of an injury, treatment of bruise
by the drainage of blood, surgical removal of dead or damaged
skin (debridement), amputation or permanent loss of use of any
part of the body, treatment of second and third degree burns.
Procedures which are diagnostic in nature are not considered by
themselves to constitute medical treatment. Visits to a physician,
physical examinations, x-ray examinations, and hospitalization
for observations, where no evidence of injury or illness is found
and no medical treatment given, do not in themselves con-stitute
medical treatment. However, if scheduled workdays are lost
because of hospitalization, the case must be reported.
Procedures which are preventative in nature also are not consid-
ered by themselves to constitute medical treatment. Tetanus and
flu shots are considered preventative in nature. First aid includes
any one-time treatment and follow-up visit for the purpose of
observation of minor scratches, cuts, burns, splinters, etc.
Ointments, salves, antiseptics, and dressings to minor injuries
are considered to be first aid.
(1) Abrasions
(i) First aid treatment is limited to cleaning a wound, soaking,
applying antiseptic and nonprescription medication, and bandag-
es on the first visit and follow-up visits limited to observation
including changing dressing and bandages. Additional cleaning
and application of antiseptic constitutes first aid where it is
required by work duties that soil the bandage.
(ii) Medical treatment includes examination for removal of
imbedded foreign material, multiple soakings, whirlpool treatment,
treatment of infection, or other professional treatments and any
treatment involving more than a minor spot-type injury. Treatment
of abrasions occurring to greater than full skin depth is consid-
ered medical treatment.
(2) Bruises
(i) First aid treatment is limited to a single soaking or applica-
tion of cold compresses, and follow-up visits if they are limited
only to observation.
(ii) Medical treatment includes multiple soakings, draining of
collected blood, or other treatment beyond observation.
(3) Bur
ns, Thermal and Chemical (resulting in destruction of
tissue by direct contact).
(i) First aid treatment is limited to cleaning or flushing the sur-
face, soaking, applying cold compresses, antiseptics or nonpre-
scription medications, and bandaging on the first visit, and follow-
up visits restricted to observation, changing bandages, or addi-
tional cleaning. Most first degree burns are amenable to first aid
treatment.
(ii) Medical treatment includes a series of treatments including
soaks, whirlpool, skin grafts, and surgical debridement (cutting
away dead skin). Most second and third degree burns require
medical treatment.
(4) Cuts and Lacerations
(i) First aid treatment is the same as for abrasions except the
application of butterfly closures for cosmetic purposes only can
be considered first aid.
(ii) Medical treatment includes the application of butterfly clo-
sures for noncosmetic purposes, sutures (stitches), surgical
debridement, treatment of infection, or other professional treat-
ment.
(5) Eye Injuries
(i) First aid treatment is limited to irrigation, removal of foreign
material not imbedded in eye, and application of nonprescription
medications. A precautionary visit (special examination) to a
physician is considered as first aid if treatment is limited to above
items, and follow-up visits if they are limited to observation only.
(ii) Medical treatment cases involve removal of imbedded for-
eign objects, use of prescription medications, or other profession-
al treatment.
(6) Inhalation of T
oxic or Corrosive Gases
(i) First aid treatment is limited to removal of the worker to
fresh air or the one-time administration of oxygen for several min-
utes.
(ii) Medical treatment consists of any professional treatment
beyond that mentioned under first aid and all cases involving loss
of consciousness.
(7) Splinters and Puncture Wounds
(i) First aid treatment is limited to cleaning the wound, removal
of foreign object(s) by tweezers or other simple techniques, appli-
cation of antiseptics and nonprescription medications, and band-
aging on the first visit. Follow-up visits are limited to observation
including changing of bandages. Additional cleaning and applica-
tions of antiseptic constitute first aid where it is required by work
duties that soil the bandage.
(ii) Medical treatment consists of removal of foreign object(s)
by physician due to depth of imbedment, size or shape of
object(s), or location of wound. Treatment for infection, treatment
of a reaction to tetanus booster, or other professional treatment,
is considered medical treatment.
(8) Sprains and Strains
(i) First aid treatment is limited to soaking, application of cold
compresses, and use of elastic bandages on the first visit.
Follow-up visits for observation, including re-applying bandage,
are first aid.
(ii) Medical treatment includes a series of hot and cold soaks,
use of whirlpools, diathermy treatment, or other professional
treatment.
DEFINITIONS
PRIVACY ACT NOTICE FOR
MINE ACCIDENT, INJURY AND ILLNESS REPORTS
G
ENERAL
This notice is given as required by Public Law 93-579 (Privacy Act of 1974) December 31, 1974, to the operators of
mines providing personal information on injury and illness reports and accident investigations.
A
UTHORITY
The authority to collect this information is Section 103 of Public Law 91-173, as amended by Public Law 95-164.
PURPOSE AND USE OF INFORMATION
The information collected will be used to help determine the cause of accidents, injuries, illnesses, and fatalities
associated with metal and nonmetallic and coal mining. The information will also be used with the intent to
prevent and reduce future accidents, injuries, fatalities, and illnesses. MSHA provides a copy of a mine operator's
or contractor's submitted form to the mine operator or contractor who submitted the form.
EFFECTS OF N
ON-DISCLOSURE
You are required to furnish the information. Without it, MSHA may not be able to help prevent miners and other workers
from becoming similarly hurt or ill in the future.
INFORMATION REGARDING PERSONAL IDENTIFICATION
UNDER PUBLIC LAW 93-579 SECTION 7(b)
MSHA asks for the last 4 digits of the social security number under authority of Section 103 of Public Law 91-173, as
amended by Public Law 95-164. This personal identification helps MSHA establish the accuracy and usefulness of
the information from injury and illness records.
BURDEN STATEMENT
P
ublic reporting burden for this collection of information is estimated to average 30 minutes per response, including
the time for reviewing instruction, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Records are retained at the mine office closest to the mine
for 5 years. 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
m
ost 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, the Office of Program Evaluation and Information
Resources, Mine Safety and Health Administration, U.S. Department of Labor, 201 12th Street South, Arlington, VA
22202, and to the Office of Management and Budget, Paperwork Reduction Project (1219-0007), Washington, DC
20503.
Persons are not required to respond to this
collection of information unless it displays a currently valid control number.
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Form 1.: Mine Accident, Injury and Illness Report (Mine Safety and Health Administration)

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Completed 19 July 2020

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