(a) Complete items 5 through 12 for each accident, occupational injury, or occupational illness.

(1) Item 5. Location and mining method. Circle the appropriate location code that was nearest to the location of the accident injury or illness. If the accident injury or illness occurred at the surface, circle only the surface location code in column (a). If the accident injury or illness occurred underground, circle only the underground location code in column (b). Where applicable, circle the underground mining method code in column (c). Applicable codes for columns (a), (b), and (c) are as follows:

(i) Column (a)—Surface location codes. If the accident injury or illness occurred at the surface of a mine, circle one of the following codes which best describes where the accident injury or illness occurred and ignore columns (b) and (c):

(ii) Column (b)—Underground location codes. If the accident injury or illness occurred underground, circle the one code which best describes where the accident injury or illness occurred:

(iii) Column (c)—Underground mining method. If the underground accident injury or illness occurred on a working section or working place, enter the code for the mining method at that working section or working place:

(2) Item 6. Date of accident injury or illness. Enter the date the accident injury or illness occurred.

(3) Item 9. Describe fully the conditions contributing to the accident injury or illness and quantify the damage or impairment. Describe what happened and the reasons therefor, identify the factors which led or contributed to the accident, injury or illness and identify any damage or impairment to the mining operation. The narrative shall clearly specify the actual cause or causes of the accident injury or illness and shall include the following:

(i) Whether the accident injury or illness involved any aspect of compliance with rules and regulations;

(ii) Whether the accident injury or illness involved mine equipment or the mining system;

(iii) Whether the accident injury or illness involved job skills and miner proficiency, training and attitude; and

(iv) Whether the accident injury or illness involved protective items relating to clothing, or protective devices on equipment.

(4) Item 10. If equipment was involved in the accident, injury or illness specify type (loader, shuttle car, dozer, etc.), name of manufacturer, and equipment model number.

(5) Item 11. Name of witness to accident injury or illness. If any miner witnessed the accident injury or illness, enter the name.

(b) Complete items 13-27 for each occupational injury, or occupational illness.

(1) Item 13. Name of injured/ill miner. Enter the miner's name (first, middle initial, and last).

(2) Item 17. Regular job title. Enter the miner's regular job title. For example: “shuttle car operator”.

(3) Item 19. Check if this injury/illness resulted in permanent total or partial disability.

(i) “Permanent total disability.” The classification for any injury or illness other than death which permanently and totally incapacitates an employee from following any gainful occupation or which results in the loss, or the complete loss of use, of any of the following in one accident injury or illness:

(A) Both eyes;

(B) One eye and one hand, or arm, or leg, or foot;

(C) Any two of the following not on the same limb: hand, arm, foot, or leg.

(ii) “Permanent partial disability.” The classification for any injury or illness other than death or permanent total disability which results in the loss, or complete loss of use, of any member or part of a member of the body, or any permanent impairment of functions of the body or part thereof, regardless of any preexisting disability of the affected member or impaired body function.

(4) Item 20. What directly inflicted injury or illness. Name the object or substance which directly affected the miner. For example: the machine or thing struck against or which struck the miner; the vapor or poison inhaled or swallowed; the chemical or non-ionizing radiation which irritated the skin; or in cases of strains or hernias, the thing lifted or pulled.

(5) Item 21. Nature of injury or illness. For injuries, use commonly used medical terms to answer this question such as puncture wound, third degree burn, fracture, dislocation, amputation. For multiple injuries, enter the injury which was the most serious. For illness, name the illness, such as pneumoconiosis, silicosis. Avoid general terms such as “hurt”, “sore”, “sick”.

(6) Item 22. Part of body injured or affected. Name the part of the body with the most serious injury. For example, if an injured employee has a bruised finger and a broken ankle, write “ankle”. If amputation, enter part of the body lost.

(7) Item 23. Occupational Illness. Circle the code from the list below which most accurately describes the illness. These are typical examples and are not to be considered the complete listing of the types of illnesses and disorders that should be included under each category. In cases where the time of onset of illness is in doubt, the day of diagnosis of illness will be considered as the first day of illness.

(i) Code 21—Occupational Skin Diseases or Disorders. Examples: Contact dermatitis, eczema, or rash caused by primary irritants and sensitizers or poisonous plants; oil acne; chrome ulcers; chemical burns or inflammations.

(ii) Code 22—Dust Diseases of the Lungs (Pneumoconioses). Examples: Silicosis, asbestosis, coal worker's pneumoconiosis, and other pneumoconioses.

(iii) Code 23—Respiratory Conditions due to Toxic Agents. Examples: Pneumonitis, pharyngitis, rhinitis, or acute congestion due to chemicals, dusts, gases, or fumes.

(iv) Code 24—Poisoning (Systemic Effects of Toxic Materials). Examples: Poisoning by lead, mercury, cadmium, arsenic, or other metals, poisoning by carbon monoxide, hydrogen sulfide or other gases; poisoning by benzol, carbon tetrachloride, or other organic solvents; poisoning by insecticide sprays such as parathion, lead arsenate; poisoning by other chemicals such as formaldehyde, plastics and resins.

(v) Code 25—Disorders Due to Physical Agents (Other than Toxic Materials). Examples: Heatstroke, sunstroke, heat exhaustion and other effects of environmental heat; freezing, frostbite and effects of exposure to low temperatures; caisson disease; effects of ionizing radiation (radon daughters, non-medical, non-therapeutic X-rays, radium); effects of nonionizing radiation (welding flash, ultra-violet rays, micro-waves, sunburn).

(vi) Code 26—Disorders Associated with Repeated Trauma. Examples: Noise-induced hearing loss; synovitis, tenosynovitis, and bursitis; Raynaud's phenomena; and other conditions due to repeated motion, vibration or pressure.

(vii) Code 29—All Other Occupational Illnesses. Examples: Infectious hepatitis, malignant and benign tumors, any form of cancer, kidney diseases, food poisoning, histoplasmosis.

(8) Item 24. Miner's work activity when injury or illness occurred. Describe exactly the activity of the injured miner when the occupational injury or occupational illness occurred. For example: “Setting temporary support prior to drilling holes for roof bolts.”

(Secs. 103 (a) and (h), and 508, Pub. L. 91-173, as amended by Pub. L. 95-164, 91 Stat. 1297, 1299, 83 Stat. 803 (30 U. S. C. 801, 813, 957))

[42 FR 65535, Dec. 30, 1977; 43 FR 1617, Jan. 11, 1978, as amended at 44 FR 52828, Sept. 11, 1979; 69 FR 26499, May 13, 2004]