"MSHA Escalation Form"
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: