Mine / Project Name*

MSHA Mine ID*

Sampler Name*

Sampling Date*

Sampling Type*

Mine Type

Pump ID / Serial Number*

Pump Make / Model

Cyclone Type*

Filter Cassette ID / Lot Number

Pre-Calibration Flow Rate (L/min)

Pre-Calibration Time

Post-Calibration Flow Rate (L/min)

Post-Calibration Time

Calibration Device Used

Flow Rate Within Tolerance (±5%)Flow Rate Within Tolerance (±5%)

Calibration Notes

Sample Location / Designation*

Occupation Sampled*

Miner Name (optional)

Mining Method

Sampling Start Time*

Sampling End Time*

Total Sampling Duration (minutes)*

Total Volume Sampled (liters)

Shift Duration (hours)

Sampling Interruptions OccurredSampling Interruptions Occurred

Filter Pre-Weight (mg)

Filter Post-Weight (mg)

Gross Weight Gain (mg)

Concentration (mg/m³)

Applicable Dust Limit (mg/m³)

Quartz Analysis RequiredQuartz Analysis Required

Compliance Status*

Analytical Laboratory

Lab Receipt Date

Sampling Notes

Free Fillable Dust Sampling Record

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