MSHA Escalation Form

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					                                        MSHA Escalation Report

Notice: This form is a documentation of a call received on the MSHA 1-800 Line. The caller was
reporting either an emergency at a mine or a hazardous condition. The information documented was
provided by the caller and was forwarded to a district office for further resolution.

SR Number:                    Contact Type:          Mine Zip Code:    County:     Is this a coal mine?
                              Phone
Reference Number:                                    City:             State:

                                              Contact Information
Anonymous:                                           Caller’s Primary Phone #:
Caller’s Name:                                       Caller’s Secondary Phone #:
Caller’s Email Address:
Name of Mine:                                        Mining Company:

Mine Identification Number :
                                              Event Information
Has anyone died?                                     How many died?
Is anyone injured?                                   How many injured?
Types of injuries:


Is anyone trapped?                                   How many trapped?
Is there a fire?
Details provided by caller:




                                          Administrative Activities
Date / Time Event Occurred:
Date / Time MSHA Notified:
District Office:

Information Name:

Date / Time District Office Notified:                    Comments:

				
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posted:4/10/2012
language:English
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