Mine Accident and Injury Report
Website: www.wvminesafety.org Rev. 2/2006
West Virginia Office of Miners’ Health, Safety & Training
Phone: (304) 558-1425 Fax: (304) 558-1282
• Section A-Identification Data
WV PERMIT NUMBER
MSHA ID NUMBER
CHECK HERE IF REPORT PERTAINS TO CONTRACTOR
WV CONTRACTOR ID NUMBER
MINE NAME
COMPANY NAME (IINJURED’S EMPLOYER)
COUNTY (MINE LOCATION)
1. Accident Code - (Circle applicable code - see instructions)
• Section B-Complete for Each Immediately Reportable Accident
01-Death 02-Serious Injury 03-Entrapment 04-Inundation 05-Gas or Dust Ignition 06-Mine Fire 07-Explosives 08-Roof Fall
09-Outburst 10-Impounding Dam 11-Hoisting 12-Offsite Injury 13-Injury Requiring Hospitalization 14-Medical Treatment 15-Loss of Consciousness
16- Inability to Perform Duties 17-Tempory Assignment 18-Transfer to Another Job
• Section C-Complete for Each Reportable Accident or Occupational Injury
2. Circle the Codes that best describe where Accident/Injury occurred and mining methods utilized
(a) Surface Location 02-Surface at Underground Mine 30-Tipple, Preparation Plant, etc. 03-Surface Mine 04 Auger Operation 05-Refuse Area
17-Shops 12 Other/Explain
(b) Underground Location 01-Shaft 02-Slope 03-Face 04-Intersection 08 Track Entry 07 Conveyor Entry 06-Other/Explain
(c) Mining Methods Utilized 01 Longwall 03-Conventional 05-Continuous 09 Continuous W/Remote 10 Extended Cut Plan
11 Retreat Mining/Pillaring 12 Continuous Haulage
3. Date of Accident ______________ 4. Time of Accident ______________ AM PM 5. Time Shift Started ______________ AM PM
6. Specific Location / Section
__________________________________________________________________________________________________
7. Describe Fully the Conditions Contributing to the Accident and Explain any Injuries That Occu