Appendix J MSHA form

(SEE INSTRUCTIONS ON REVERSE SIDE OF COPY 2)

Mo.

1. Persons Working, Employee-Hours, and Coal Production
(1) Operation Sub Unit Code(s) C o d e (2) A v e r a g e n u m b e r
(3) Total employee
prevlously reported:
of persons working
hours worked
during quarter
during the quarter
Underground
Underground
Mine

Date Report Completed

DOL - MSHA - PEIR - OIEI
P.O. Box 25367
Denver, Colorado 80225 - 0367

Quarterly Mine Employment
and Coal Production Report

For

Quarter

Day

Mail Before

(4) Production of clean coal
during quarter, (short
tons)

Check here if this report is being submitted by a contractor

01

If any information below is incorrect, please enter correct information here:
County:

Surface Shops,
Yards, etc.

02

Surface
Mine

Strip, Open Pit,
or Quarry

03

(including
associated
shops and
yards)

Auger (Coal Mine Only)

04

Culm Bank or Refuse
Pile (Coal Mine Only)

05

Dredge

06

County

Other Surface Mining
(Metal/Nonmetal Only)

12

MSHA ID Number

Operation Name:
Operating Company Name and Mailing Address:

Contractor ID

17

Independent Shops or Yards
Mill Operations, Preparation Plants, or
Breakers
(include associated shops and yards)
Office (professional and clerical
employees at the mine or plant working
in an office)

Operation Name

30
99

Operating Company Name and Mailing Address

2. Other Reportable Data
How many MSHA reportable injuries or illnesses did you have this quarter?
Person to be contacted
regarding this report:

Name
Title

MSHA Form 7000-2, July 97, (revised)

Yr.

Year

Tel. No. (

)

-

area code
OMB Number 1219-0007; Approval Expires Apri 30, 2011

Copy 1 - Return to MSHA (Denver)

Quarterly Mine Employment
and Coal Production Report

U.S. Department of Labor
Mine Safety and Health Administration

OBM Control Number 1219-0007; Approval Expires April 30, 2011
This report is required by law (30 U.S.C. subsection 813; 30 C.F.R. Part 50). Failure to report may result in the issuance of a
citation or order under 30 U.S.C. subsection 814 to an operator of a coal or other mine, the assessment of a civil penalty
against an operator of a coal or other mine under 30 U.S.C. subsection 820(a), and the institution of a civil action under 30 U.S.
C. subsection 818. An individual who knowingly makes a false statement in any report shall, upon conviction, be punished by a
fine of not more than $10,000 or by imprisonment for not more than 5 years, or both, under 30 U.S.C. subsection 820(f).
Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies,
conceals or covers up by any trick scheme, or device, a material fact, or makes or uses any false writing or document knowing
the same to contain any false, fictitous or fraudulent statement or entry, shall be fined under 18 U. S. C. or imprisioned not
more than five years, or both, under 18 U. S. C. subsection 1001.

Important:

(INSTRUCTIONS)

This form must be completed and mailed or faxed within 15 days after the end of each calendar quarter.
1. Fill out this form as completely as possible and return Copy 1 of this report to:
MSHA
OR
You may FAX Copy 1 to Fax # 1- 888 - 231 - 5515
PEIR - Office of Injury and Employment Information
P.O. BOX 25367
Denver, CO 80225-0367
2. If it is necessary to make any address changes, indicate correct information on this form.
3. When pre-addressed, this form is only for the operation with I. D. number as shown. Do not use for any other
operation.
4. Sand and Gravel operators report employment data under code 03 or 06 as appropriate, except for data on office
workers which should be reported under code 99.
5. All mine operators and independent contractors reporting as required by 30 C.F.R. Part 50, should show persons
working and employee hours worked; those producing coal should also show production date.
6. Independent Contractors should complete quarterly only one form for activities at all coal locations, and one
form for activities at metal and nonmetal locations.
The public reporting burden for this collection of Information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing date sources, gathering and maintaining the date needed, and completing and reviewing the collection of Information.
Send comments regarding this estimated response time or any other aspect of this collection of information, including suggestions for reducing this
burden, to Mine Safety and Health Administration, U.S. Department of Labor, 1100 Wilson Boulevard, Arlington, VA 22209-3939.
Persons are not required to respond to this collection of information unless this form displays a currently valid OMB control number.
MSHA Form 7000-2, July 97 (revised)