Form MS-08 Accident/Injury Report Form - Nevada

Form MS-08 is a Nevada Department of Business and Industry form also known as the "Accident/injury Report Form". The latest edition of the form was released in May 1, 2008 and is available for digital filing.

Download a PDF version of the Form MS-08 down below or find it on Nevada Department of Business and Industry Forms website.

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DIVISION OF INDUSTRIAL RELATIONS
Immediate Notification of an Accident
DEPARTMENT OF BUSINESS & INDUSTRY
must be made by telephone to the
MINE SAFETY & TRAINING SECTION
Carson City office in addition to the
400 W. King Street, Suite 210
completion of this form.
Carson City, NV 89703
Email: mines@business.nv.gov
775-684-7085
Fax: 775-687-8259
MSHA ID NO.
CONTRACTOR ID NO.
County
Mine Name
Company Name
Accident Information:
Date of Accident
Time of Accident
Time Shift Started
am
am
Month
Day
Year
pm
pm
Where in or at the Mine did the accident occur
Check if Underground Mine
Check if Surface Mine or Other
Name of Injured Employee
Sex
Date of Birth
Male
Female
Experience
Years
Weeks
Job Title
This job title
At this Mine
Employee Work Activity when Injury or Illness occured
Total Mining Experience
Name of Immediate Supervisor
Telephone Number
Describe the conditions contributing to the Accident/Injury and damage or impairment to individual:
Part of Body Injured or Affected
Check if injury resulted in death
Check if injury resulted in permanent disability
(Include amputation, loss of use & permanent total disability)
Equipment Involved
Type
Manufacturer
Model #
Name of Witness to Accident/Injury
Job Title
Date returned to work at full capacity
Number of Days Away
Number of Days Restricted
from work
Work Activity
Month
Day
Year
Person Completing Form
Title
Date Report Prepared
Area Code and Phone Number
(month, day, year)
MAIL, FAX OR EMAIL THIS FORM
TO MINE SAFETY & TRAINING
400 W. KING STREET, SUITE 210
CARSON CITY, NV 89703
MS-08 (5/08)
R:\mines\forms\correct with changes\ms-08industryaccident.doc
DIVISION OF INDUSTRIAL RELATIONS
Immediate Notification of an Accident
DEPARTMENT OF BUSINESS & INDUSTRY
must be made by telephone to the
MINE SAFETY & TRAINING SECTION
Carson City office in addition to the
400 W. King Street, Suite 210
completion of this form.
Carson City, NV 89703
Email: mines@business.nv.gov
775-684-7085
Fax: 775-687-8259
MSHA ID NO.
CONTRACTOR ID NO.
County
Mine Name
Company Name
Accident Information:
Date of Accident
Time of Accident
Time Shift Started
am
am
Month
Day
Year
pm
pm
Where in or at the Mine did the accident occur
Check if Underground Mine
Check if Surface Mine or Other
Name of Injured Employee
Sex
Date of Birth
Male
Female
Experience
Years
Weeks
Job Title
This job title
At this Mine
Employee Work Activity when Injury or Illness occured
Total Mining Experience
Name of Immediate Supervisor
Telephone Number
Describe the conditions contributing to the Accident/Injury and damage or impairment to individual:
Part of Body Injured or Affected
Check if injury resulted in death
Check if injury resulted in permanent disability
(Include amputation, loss of use & permanent total disability)
Equipment Involved
Type
Manufacturer
Model #
Name of Witness to Accident/Injury
Job Title
Date returned to work at full capacity
Number of Days Away
Number of Days Restricted
from work
Work Activity
Month
Day
Year
Person Completing Form
Title
Date Report Prepared
Area Code and Phone Number
(month, day, year)
MAIL, FAX OR EMAIL THIS FORM
TO MINE SAFETY & TRAINING
400 W. KING STREET, SUITE 210
CARSON CITY, NV 89703
MS-08 (5/08)
R:\mines\forms\correct with changes\ms-08industryaccident.doc

Download Form MS-08 Accident/Injury Report Form - Nevada

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