Get Mine Accident And Injury Report

This guide provides essential steps for accurately completing the Mine Accident and Injury Report online. Properly filling out this form is crucial for effective reporting and analysis of mining accidents and injuries.

Follow the steps to accurately complete the Mine Accident and Injury Report.

1. Press the ‘Get Form’ button to access the document and open it in your editing interface.
2. In Section A, fill in your identification data. This includes your West Virginia permit number, MSHA ID number, mine name, and the contractor ID number if applicable. Enter the company name of the injured person's employer and the county where the mine is located.
3. Circle the applicable accident code in Section B that best describes the incident. Choose one from the list of codes that includes options such as death, serious injury, or other specific occurrences.
4. For Section C, indicate the location of the accident by circling the relevant codes for surface or underground. Make sure to describe the mining methods utilized as well.
5. Fill in the date and time of the accident, as well as the time shift started. Provide a specific location or section where the accident occurred.
6. In Section C, describe the conditions that contributed to the accident and detail the injuries sustained. Be as specific as possible.
7. List any equipment involved, specifying the type and manufacturer. Also, record the number of reportable injuries resulting from the incident.
8. Provide information about the witness to the accident, including name details, and then fill in the injured employee's name and social security number (last four digits).
9. Complete additional details such as gender, date of birth, regular job title, and the nature of the injury. Consider checking if the injury resulted in permanent disability.
10. Detail the nature of medical treatment administered or hospitalization received and describe the employee's work activity at the time of the injury.
11. Indicate any personal protective equipment in use when the accident occurred and the experience levels of the employee in their job title, at that mine, and their total mining experience.
12. In Section D, provide return to duty information if applicable, such as date returned to regular job and number of days away from work. Fill out the report completions with the person’s name and signature, as well as contact details.
13. Once completed, review the form for accuracy and ensure all sections are filled in. Save your changes, then download, print, or share the document as needed.

Complete the Mine Accident and Injury Report online today to ensure accurate documentation of incidents.