Ndependent Contractor Monthly Report Form - West Virginia Office Of Miners' Health, Safety And Training
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1STATE OF WEST VIRGINIA
’
,
OFFICE OF MINERS
HEALTH
SAFETY AND TRAINING
I
NDEPENDENT CONTRACTOR MONTHLY REPORT
06/2012
MONTH:
YEAR:
WV CONTRACTOR ID NO.: C
)
(E
: C00001234
XAMPLE
COMPANY NAME
ADDRESS:
M
T
W
V
M
S
T
M
: (
)
ONTHLY
OTALS FOR WORKING AT
EST
IRGINIA
INE
ITES
HIS
ONTH
PLEASE COMPLETE THIS SECTION
1.
TOTAL NUMBER OF EMPLOYEES:
2.
TOTAL NUMBER OF MANHOURS:
3.
TOTAL NUMBER OF INJURIES:
,
W
V
EMPLOYEES
HOURS AND INJURIES AT
EST
IRGINIA MINES
(
WV
)
PROVIDE THIS INFORMATION IN THE SPACES BELOW FOR EACH
MINE PROVIDED SERVICES
BREAKDOWN BY SITE:
1. MINING COMPANY____________________________ WV MINE PERMIT NO.:_________________ INJURIES: ______________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _____________ TOTAL EMPLOYEE HRS: ______________
2. MINING COMPANY____________________________ WV MINE PERMIT NO.:_________________ INJURIES: _____________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _______________ TOTAL EMPLOYEE HRS: ______________
3. MINING COMPANY____________________________ WV MINE PERMIT NO.:_________________ INJURIES: ______________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _______________ TOTAL EMPLOYEE HRS: ______________
4. MINING COMPANY____________________________ WV MINE PERMIT NO.:_________________ INJURIES: ______________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _______________ TOTAL EMPLOYEE HRS: ______________
5. MINING COMPANY___________________________ WV MINE PERMIT NO.:_________________ INJURIES: ______________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _______________ TOTAL EMPLOYEE HRS: ______________
6. MINING COMPANY____________________________ WV MINE PERMIT NO.:_________________ INJURIES: ______________
# OF CONTACTOR EMPLOYEES ON THIS SITE: _______________ TOTAL EMPLOYEE HRS: ______________
:
MAIL COMPLETED REPORT TO
SIGNATURE
’
,
&
OFFICE OF MINERS
HEALTH
SAFETY
TRAINING
PRINTED NAME
#7 P
C
D
- SUITE 2
LAYERS
LUB
RIVE
TITLE
C
, WV 25311-1626
HARLESTON
# 304-558-1425
_______________
:
PHONE
DATE
COMPANY PHONE NO
Fax #: 304-558-6091
:
EMAIL ADDRESS
1. On or before the end of each calendar month, each independent contractor registered with the West Virginia Office of Miner’s Health Safety and Training as
required by West Virginia code 22A-2-63(e), shall file with the Director a report covering the preceding calendar month on forms approved by the Director. Such
report shall contain the following information for each mine(s) where independent contractors performed work or provided services: (1) The total number of
employees performing services at a mining operation. (2) The total employee hours worked at a mining operation. (3) The total reported accidents and
occupational injuries that occurred to employees while performing services at a mining operation pursuant to Series 19. (4) The mine(s) identification number
where employee hours were worked and/or where the accident or occupational injury occurred.
2. Reports must be filed each month for all Independent Contractors holding valid WV Office of Miners’ Health Safety and Training permits even if no work was
performed on mine property. In this case contractors would report “zero” employee hours and employment, if applicable. Note: To apply for online reporting go
to
under Online Reporting click on monthly reporting for independent contractors and submit a request.
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