Form DMM-104C "Accident Report" - Virginia

What Is Form DMM-104C?

This is a legal form that was released by the Virginia Department of Mines, Minerals and Energy - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Virginia Department of Mines, Minerals and Energy;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMM-104C by clicking the link below or browse more documents and templates provided by the Virginia Department of Mines, Minerals and Energy.

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Division of Mineral Mining
900 Natural Resources Drive, Suite 400
Charlottesville, VA 22903
(434) 951-6310
ACCIDENT REPORT
Company/Mine Name
DMM Permit No.
MSHA ID
Accident Date
Time
Shift
County
Telephone No.
Contractor Employee:
Yes
No
Contractor Name
DMM Contractor No.
Address
Telephone No.
Type:
Medical Treatment
Serious Injury
Fatality
Name of Injured
Age
GMM Certification Number
Date of Birth
Regular Occupation
Total Experience (yr/mo)
Occupation at Time of Accident
Experience (yr/mo)
Location of Accident:
Mine/Pit
Crushing/Processing
Shop
Load out/Stockpiles
Other (specify)
Type of Equipment Involved:
Mobile Equipment
Mine Drill
Crushing
Screening
Conveyors
Bins/Hoppers
Walkways/Platforms/Ladders
Welding/Cutting
Hand tools
Other (specify)
Body Part Injured:
Eyes
Head
Hand
Arm
Foot
Leg
Back
Neck
Chest
Other (specify)
Nature of Injury
Brief Description of Accident
______
Preventive Measures Taken
Person Completing Form
Date Completed
Title
Phone Number
DMM-104C
Rev 05/16
Division of Mineral Mining
900 Natural Resources Drive, Suite 400
Charlottesville, VA 22903
(434) 951-6310
ACCIDENT REPORT
Company/Mine Name
DMM Permit No.
MSHA ID
Accident Date
Time
Shift
County
Telephone No.
Contractor Employee:
Yes
No
Contractor Name
DMM Contractor No.
Address
Telephone No.
Type:
Medical Treatment
Serious Injury
Fatality
Name of Injured
Age
GMM Certification Number
Date of Birth
Regular Occupation
Total Experience (yr/mo)
Occupation at Time of Accident
Experience (yr/mo)
Location of Accident:
Mine/Pit
Crushing/Processing
Shop
Load out/Stockpiles
Other (specify)
Type of Equipment Involved:
Mobile Equipment
Mine Drill
Crushing
Screening
Conveyors
Bins/Hoppers
Walkways/Platforms/Ladders
Welding/Cutting
Hand tools
Other (specify)
Body Part Injured:
Eyes
Head
Hand
Arm
Foot
Leg
Back
Neck
Chest
Other (specify)
Nature of Injury
Brief Description of Accident
______
Preventive Measures Taken
Person Completing Form
Date Completed
Title
Phone Number
DMM-104C
Rev 05/16