Title Page

  • MSHA citation

  • Conducted on

  • Prepared by

  • Location
  • What is the cited condition?

  • Cited CFR #

  • Citation photos

  • Specific Location/ Equipment

  • Organization

  • Division

  • Department

  • Department

  • Department

  • Department

  • Department

  • Department

  • Division

  • Department

  • Department

  • Department

  • Department

  • Contractor Name:

  • Division

  • Likelihood

  • Severity

  • Significant and Substantial

  • Negligence

  • Does this citation need an RCA completed?

  • Should this Citation be conferenced?

  • What are the Mitigating Circumstances?

  • Mitigating Photos (notes, evidence, supporting documentation)

  • Terminated?

  • Termination Photo

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