Mine / Project Name*

MSHA Mine ID*

Area / Entry Examined*

Examination Type*

Examiner Name*

Examination Date*

Examination Time*

Shift

Roof Condition Rating*

Rib Condition Rating*

Loose Material Present (Roof / Rib)Loose Material Present (Roof / Rib)

All Support Systems Intact (Bolts, Timbers, Cribs)All Support Systems Intact (Bolts, Timbers, Cribs)

Additional Roof & Rib Notes

Ventilation Adequacy*

Estimated Air Quantity (CFM)

Methane Reading (%)

Methane Alarm TriggeredMethane Alarm Triggered

All Ventilation Controls in Place (Stoppings, Overcasts, Regulators)All Ventilation Controls in Place (Stoppings, Overcasts, Regulators)

Ventilation Notes

Coal Dust Accumulations*

Float Coal Dust PresentFloat Coal Dust Present

Rock Dust Applied and AdequateRock Dust Applied and Adequate

Oil / Grease Accumulations PresentOil / Grease Accumulations Present

Water Accumulations PresentWater Accumulations Present

Accumulations Description

Self-Rescuers Present and AccessibleSelf-Rescuers Present and Accessible

Fire Extinguishers ServiceableFire Extinguishers Serviceable

First Aid Kit StockedFirst Aid Kit Stocked

Primary and Alternate Escapeways ClearPrimary and Alternate Escapeways Clear

Communication System WorkingCommunication System Working

Lifeline in Place (if required)Lifeline in Place (if required)

Emergency Equipment Notes

Unsafe Conditions Noted

Overall Conditions Description

Miners Notified of Unsafe ConditionsMiners Notified of Unsafe Conditions

Area Evacuated Due to Unsafe ConditionsArea Evacuated Due to Unsafe Conditions

Corrective Actions Taken / Required

Examiner Confirms Report is Accurate and Complete*Examiner Confirms Report is Accurate and Complete

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