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?
Reference Number: City: State:
Anonymous: Caller’s Primary Phone #:
Caller’s Name: Caller’s Secondary Phone #:
Caller’s Email Address:
Name of Mine: Mining Company:
Mine Identification Number :
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:
Date / Time Event Occurred:
Date / Time MSHA Notified:
Date / Time District Office Notified: Comments: