Fillable Form Approved: OMB Number 1219-0144 Approval Expires July (Mine Safety and Health Administration)

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Form Approved: OMB Number 1219-0144 Approval Expires July (Mine Safety and Health Administration)

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Country of origin: US
File type: PDF

U.S.A. forms for Mine Safety and Health Administration (MSHA)

BROWSE MINE SAFETY AND HEALTH ADMINISTRATION (MSHA) (VA) FORMS

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Operator’s Annual Certification of Mine Rescue Team Qualifications
Form Approved: OMB Number 1219-0144 Approval Expires July 31, 2023
This form is affected by the Privacy Act of 1974
Public reporting burden for this collection of information is estimated to average 31 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing the form. This collection of information is mandatory. You are not required to respond to this collection of information unless it displays a valid
OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: to DOL/MSHA, Office of Standards Regulations and Variances, 201
12th Street South, Suite 401, Arlington, VA 22202-5452, Paperwork Reduction Project (1219-0144), NOTE: Do not send your completed form to this address.
MSHA Mine ID No.: Contractor ID No.: Company Name:
Mine Name:
Mine size: Large Smal
l
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Team is available at all times when
miners are underground
Team Name:
Type of Team: Mine-site Composite
Contract
State-sponsored
Mine Rescue Team is available within 1-hour ground travel time from the Mine Rescue Station
Address of Mine Rescue Station:
Appropriate mine rescue equipment
is provided, inspected, tested, &
maintained
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2 3 4 5
Alternate
Member’s name
Employer’s name
Experience working
in underground coal
mine
Physically fit
Initial 20 hr Initial 20 hr Initial 20 hr Initial 20 hr Initial 20 hr Initial 20 hr New member training
Annual training Refresher training
totals 96 hr or more
Refresher training
totals 96 hr or more
Refresher training
totals 96 hr or more
Refresher training
totals 96 hr or more
Refresher training
totals 96 hr or more
Refresher training
totals 96 hr or more
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec
8 hr training every
2 mos; includes
wearing apparatus
for 2 hr
MSHA Form 2000-224, Aug. 2015 revised (Mailing Address), Page 1 of 2
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Operator’s Annual Certification of Mine Rescue Team Qualifications
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Trains at this mine
(Insert dates)
I certify the information above is true and accurate to the best of my knowledge.
Printed Name &
Signature:
Date: Position held at the mine:
Use of this form is optional.
An underground coal mine operator may file a copy of this form with the appropriate District Manager for each of the two designated
mine rescue teams, that provide coverage for this mine, to certify that each team meets the requirements of 30 CFR Part 49 Subpart B.
MSHA Form 2000-224, Aug. 2015, revised (Mailing Address), Page 2 of 2
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Form Approved: OMB Number 1219-0144 Approval Expires July (Mine Safety and Health Administration)

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Completed 25 September 2021

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