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Appendix B Mine Accident, Injury and Illness Report U.S. Department of Labor Mine Safety and Health Administration 157

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158 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES U.S. Department of Labor • • Male • Female For Official Use Only Answer 30 & 31 when case is closed

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APPENDIX B 159 MINE ACCIDENT, INJURY, AND ILLNESS REPORT MSHA FORM 7000-1 Section 50.20 of Part 50, Title 30, Code of Federal Regulations, MSHA ID Number is the number assigned to the operation by requires a report to be prepared and filed with MSHA of each acci- MSHA. If you are unsure of your number assignment, contact the dent, occupational injury, or occupational illness occurring at your nearest MSHA Mine Safety and Health District or Subdistrict Office. operation. The requirement includes all accidents, injuries, and ill- Reports on contractor activities at mines must include an MSHA- nesses as defined in Part 50 whether your employees or a contrac- assigned contractor ID Number as well as the 7-digit operation ID. tor's employees are involved. A Form 7000-1 shall be completed and mailed within ten working days after an accident or occupa- Show mine name and company name. Independent contractors tional injury occurs, or an occupational illness is diagnosed. should provide the mine name and show the contractor name under "company name. " 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 Section B- COMPLETE FOR EACH ACCIDENT IMMEDIATELY for relief under 30 U.S.C. 9818 respecting an operator of a coal REPORTABLE TO MSHA or other mine, and assessment of a civil penalty against an oper- Section B is to be completed only when your operation has an ator of a coal or other mine under 30 U.S.C. 9820(a). An individ- accident that must be reported immediately to MSHA. Circle ual who, being subject to the Federal Mine Safety and Health Act code 02 "Serious Injury" only if the injury has a reasonable poten- of 1977 (30 U.S.C. 9801 at seq.) knowingly makes a false state- tial to cause death. For additional detail on those specific kinds of ment in any report can be punished by a fine of not more than accidents see Section 50.10 of Part 50. When it is necessary to $10,000 or by imprisonment for not more than 5 years, or both, complete Section B, circle the applicable accident code; give the under 30 U.S.C. §820.(f). Any individual who knowingly and will- name of the investigator (the person heading the investigating fully makes any false, fictitious, or fraudulent statements, con- team on the accident); show the date the investigation was start- ceals a material fact, or makes a false, fictitious, or fraudulent ed; and describe briefly the steps taken to prevent a recurrence entry, with respect to any matter within the jurisdiction of any of such an accident. 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 Section C- COMPLETE FOR EACH REPORTABLE ACCIDENT, both, under 18 U.S.C. 91001. INJURY, OR ILLNESS Section C must be completed on each form submitted to MSHA. REPORTING INSTRUCTIONS Item 5. If you are reporting an occurrence at a surface mine or Form 7000-1 consists of four sheets, an original (page 1) and other surface activity, circle the code which best describes the acci- three copies. The original will be mailed to MSHA, Denver Safety dent location in (a). Surface Location; do not mark any codes in (b) and Health Technology Center. The first copy (page 2) will be or (c). If you are reporting an occurrence in an underground mine, mailed to the appropriate local MSHA District or Subdistrict circle the code which best describes the underground location in (b) Office. Envelopes are included with the forms for mailing to those Underground Location and in (c) Underground Mining Method. offices. If the mailed forms do not show return to duty information Items 6, 7, and 8. Show the date and time of the occurrence and on an injured employee, complete and mail the second copy the time the shift started in which the accident/incident occurred (page 3) to MSHA, Denver Safety and Health Technology Center, or was observed. when the employee returns to regular job at full capacity or a Item 9. Describe fully the conditions contributing to the occur- final disposition is made on the injury or illness. The third copy rence. Detailed descriptions of the conditions provide the basis (page 4) is to be retained at the mine for a period of five years. It for accident and injury analyses which are intended to assist the is important to remember that a Form 7000-1 is required on each mining industry in preventing future occurrences. Please see Part accident as defined in 30 CFR Part 50 whether any person was 50 for detail on what your narrative should include. injured or not. A form is required on each individual becoming Item 10. If equipment was involved in the occurrence, name the injured or ill, even when several were injured or made ill in a sin- type of equipment, the manufacturer, and the model number of gle occurrence. The principal officer in charge of health and safe- the equipment. ty at the mine or the supervisor of the mine area in which the Item 11. If there was a witness to the occurrence, give the name accident, injury, or illness occurred shall be responsible for com- of the witness. pleting the Form 7000-1. Note: First aid cases (those for which Item 12. If the occurrence resulted in one or more injuries, report the no medical treatment was received, no time was lost, and no number. A separate report must be made on each injured person. restriction of work, motion, or loss of consciousness occurred) Item 13. Show the name of the injured person. [Note: In these need not be reported. instructions, "injured person" means a person either injured or ill.] Item 14. Indicate the sex of the injured person. SPECIFIC INSTRUCTIONS Item 15. Show the date of birth of the injured person. Item 16. Show the last four digits of the injured person's Social Detailed instructions for completing Form 7000-1 are contained in Security Number. Part 50. A copy of Part 50 was sent to every active and intermit- Item 17. Give the regular job title of the injured person at the tently active mine and independent mining contractor. If you do time he was injured. not have a copy, you may obtain one from your local MSHA Mine Item 18. Check this box if the injury or illness resulted in death. Safety and Health District or Subdistrict Office. Item 19. Check this box if the injury or illness resulted in a per- manent disability. A permanent disability is any injury or occupa- Section A- IDENTIFICATION DATA tional illness other than death which results in the loss (or com- Check the report category indicating whether your operation is in plete loss of use) of any member (or part of a member) of the the metal/nonmetal mining industry or the coal mining industry. body, or a permanent impairment of functions of the body, or which permanently and totally incapacitates the injured person from following any gainful occupation.

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160 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES Item 20. Name the object or substance that directly caused the Item 24. Describe what the employee was doing when he or injury or illness. she became injured or ill. Item 21. Report the nature of injury or illness by naming the ill- Items 25, 26, and 27. Show the number of weeks (or years and ness; or for injuries, by using common medical terms such as weeks) of experience of the injured person at the job title (indicated puncture wound, third degree burn, fracture, etc. For multiple in Item 17), at your operation, and his/her total mining experience. injuries, enter the injury which was the most serious. Avoid gener- al terms such as hurt, sore, sick, etc. Section D - RETURN TO DUTY INFORMATION Item 22. Name the part of body with the most serious injury. Section D is to be completed in full when all return-to-duty infor- Item 23. Occupational illness is any abnormal condition or disor- mation is available. If the information is not available within ten der, other than one resulting from an occupational injury, which working days after a reportable occurrence, then the first two falls into the following categories: pages are sent to MSHA without Section D being completed; PAGE 3 is then mailed to DSHTC- with full information when the Code 21 - Occupational Skin Diseases or Disorders. data are available. Until all the items are answered and the Examples: Contact dermatitis, eczema, or rash caused by report sent to DSHTC-DMIS, the occurrence remains an open primary irritants and sensitizers or poisonous plants; oil case. acne; chrome ulcers; chemical burns or inflammations; etc. Code 22 - Dust Diseases of the Lungs (Pneumoconioses). Item 28. If the injured person was transferred or terminated as a Examples: Silicosis, asbestosis, coal worker’s pneumo- result of the injury or illness, check the box and answer items 29, coniosis, byssinosis, and other pneumoconioses. 30, and 31. Code 23 - Respiratory Conditions Due to Toxic Agents. Item 29. Show the date that the injured person returned to his Examples: Pneumonitis, pharyngitis, rhinitis, or acute regular job at full capacity or was transferred or terminated. This congestion due to chemicals, dusts, gases, or fumes; etc. date should indicate when the count of days away from work Code 24 - Poisoning (Systemic Effects of Toxic Materials). and/or days of restricted work activity have stopped. Examples: Poisoning by lead, mercury, cadmium, arse- Item 30. Show the number of workdays 1/ the injured person did nic, or other metals, poisoning by carbon monoxide, hy- not report to his place of employment, i.e., number of days away drogen sulfide, or other gases; poisoning by benzol, car- from work. bon tetrachloride, or other organic solvents; poisoning Item 31. Show the number of workdays the injured person was by insecticide sprays such as parathion, lead arsenate; on restricted work activity; do not include days away from work poisoning by other chemicals such as formaldehyde, reported in Item 30. plastics, and resins; etc. Code 25 - Disorders Due to Physical Agents (Other than At the bottom of the form, show the name of the person who Toxic Materials). Examples: Heatstroke, sunstroke, completed the form; the date the report was prepared; and the heat exhaustion and other effects of environmental heat; telephone number where the person who completed the form freezing, frostbite and effects of exposure to low temper- may be reached. atures; caisson disease; effects of ionizing radiation (iso- topes, x-rays, radium); effects of nonionizing radiation 1/ Note: The number of lost workdays should not include the day (welding flash, ultraviolet rays, microwaves, sunburn); etc. of injury or onset of illness, or any days on which the employee Code 26 - Disorders Associated with Repeated Trauma. was not previously scheduled to work even though able to work, Examples: Noise-induced hearing loss; synovitis, teno- such as holidays or plant closures synovitis, 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.

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APPENDIX B 161 DEFINITIONS (1 ) "Coal or other mine" means (a) an area of land from which treatment of infection, or other professional treatments and any minerals are extracted in nonliquid form or, if in liquid form, are treatment involving more than a minor spot-type injury. Treatment extracted with workers underground, (b) private ways and roads of abrasions occurring to greater than full skin depth is consid- appurtenant to such area, and (c) lands, excavations, under- ered medical treatment. ground passageways, shafts, slopes, tunnels and workings, (2) Bruises structures, facilities, equipment, machines, tools, or other proper- (i) First aid treatment is limited to a single soaking or applica- ty including impoundments, retention dams, and tailings ponds, tion of cold compresses, and follow-up visits if they are limited on the surface or underground, used in, or to be used in, or only to observation. resulting from, the work of extracting such minerals from their (ii) Medical treatment includes multiple soakings, draining of natural deposits in nonliquid form, or if in liquid form, with workers collected blood, or other treatment beyond observation. underground, or used in, or to be used in, the milling of such min- (3) Burns, Thermal and Chemical (resulting in destruction of erals, or the work of preparing coal or other minerals, and tissue by direct contact). includes custom coal preparation facilities. In making a determi- (i) First aid treatment is limited to cleaning or flushing the sur- nation of what constitutes mineral milling for purposes of this Act, face, soaking, applying cold compresses, antiseptics or nonpre- the Secretary shall give due consideration to the convenience of scription medications, and bandaging on the first visit, and follow- administration resulting from the delegation to one Assistant up visits restricted to observation, changing bandages, or addi- Secretary of all authority with respect to the health and safety of tional cleaning. Most first degree burns are amenable to first aid miners employed at one physical establishment. treatment. (2) "Operator" means any owner, lessee, or other person (ii) Medical treatment includes a series of treatments including who operates, controls, or supervises a coal or other mine or any soaks, whirlpool, skin grafts, and surgical debridement (cutting designated independent contractor performing services or con- away dead skin). Most second and third degree burns require struction at such mine. medical treatment. (3) "Occupational injury" means any injury to a worker (4) Cuts and Lacerations which occurs at a mine for which medical treatment is adminis- (i) First aid treatment is the same as for abrasions except the tered, or which results in death, loss of consciousness, inability to application of butterfly closures for cosmetic purposes only can perform ail job duties on any day after an injury, or transfer to be considered first aid. another job. (ii) Medical treatment includes the application of butterfly clo- (4) "Occupational illness" means an illness or disease of a sures for noncosmetic purposes, sutures (stitches), surgical worker which may have resulted from work at a mine or for debridement, treatment of infection, or other professional treat- which an award of compensation is made. ment. (5) "Medical treatment" means treatment, other than first (5) Eye Injuries aid, administered by a physician or by a registered medical pro- (i) First aid treatment is limited to irrigation, removal of foreign fessional acting under the orders of a physician. material not imbedded in eye, and application of nonprescription medications. A precautionary visit (special examination) to a DIFFERENCES BETWEEN physician is considered as first aid if treatment is limited to above MEDICAL TREATMENT AND FIRST AID items, and follow-up visits if they are limited to observation only. (ii) Medical treatment cases involve removal of imbedded for- Medical treatment includes, but is not limited to, the suturing of eign objects, use of prescription medications, or other profession- any wound, treatment of fractures, application of a cast or other al treatment. professional means of immobilizing an injured part of the body, (6) Inhalation of Toxic or Corrosive Gases treatment of infection arising out of an injury, treatment of bruise (i) First aid treatment is limited to removal of the worker to by the drainage of blood, surgical removal of dead or damaged fresh air or the one-time administration of oxygen for several min- skin (debridement), amputation or permanent loss of use of any utes. part of the body, treatment of second and third degree burns. (ii) Medical treatment consists of any professional treatment Procedures which are diagnostic in nature are not considered by beyond that mentioned under first aid and all cases involving loss themselves to constitute medical treatment. Visits to a physician, of consciousness. physical examinations, x-ray examinations, and brief hospitaliza- (7) Splinters and Puncture Wounds tion for observations, where no evidence of injury or illness is (i) First aid treatment is limited to cleaning the wound, removal found and no medical treatment given, do not in themselves con- of foreign object(s) by tweezers or other simple techniques, appli- stitute medical treatment. However, if scheduled workdays are cation of antiseptics and nonprescription medications, and band- lost because of hospitalization, the case must be reported. aging on the first visit. Follow-up visits are limited to observation Procedures which are preventative in nature also are not consid- including changing of bandages. Additional cleaning and applica- ered by themselves to constitute medical treatment. Tetanus and tions of antiseptic constitute first aid where it is required by work flu shots are considered preventative in nature. First aid includes duties that soil the bandage. any one-time treatment and follow-up visit for the purpose of (ii) Medical treatment consists of removal of foreign object(s) observation of minor scratches, cuts, burns, splinters, etc. by physician due to depth of imbedment, size or shape of Ointments, salves, antiseptics, and dressings to minor injuries object(s), or location of wound. Treatment for infection, treatment are considered to be first aid. of a reaction to tetanus booster, or other professional treatment, (1) Abrasions is considered medical treatment. (i) First aid treatment is limited to cleaning a wound, soaking, (8) Sprains and Strains applying antiseptic and nonprescription medication, and bandag- (i) First aid treatment is limited to soaking, application of cold es on the first visit and follow-up visits limited to observation compresses, and use of elastic bandages on the first visit. including changing dressing and bandages. Additional cleaning Follow-up visits for observation, including re-applying bandage, and application of antiseptic constitutes first aid where it is are first aid. required by work duties that soil the bandage. (ii) Medical treatment includes a series of hot and cold soaks, (ii) Medical treatment includes examination for removal of use of whirlpools, diathermy treatment, or other professional imbedded foreign material, multiple soakings, whirlpool treatment, treatment.

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162 IMPROVING SELF-ESCAPE FROM UNDERGROUND COAL MINES PRIVACY ACT NOTICE FOR MINE ACCIDENT, INJURY AND ILLNESS REPORTS GENERAL 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. AUTHORITY 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 associat- ed 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. EFFECTS OF NON-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, which is not unique to any individual, helps MSHA establish the accuracy and usefulness of the information from injury and illness records. BURDEN STATEMENT Public 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. This is a mandatory collection of information as required by 3 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, the the Office of Program Evaluation and Information Resources, Mine Safety and Health Administration, U.S. Department of Labor, Room 2301, 1100 Wilson Boulevard, Arlington, VA 22209-3939, and to the Office of Management and Budget, Paperwork Reduction Project (1219-0007), Washington, D.C. 20503. Persons are not required to respond to this collection of information unless it displays a currently valid control number.