Fillable MSHA Form 5000-41: Safety and Health Activity Certification (Mine Safety and Health Administration)

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MSHA Form 5000-41: Safety and Health Activity Certification (Mine Safety and Health Administration)

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The MSHA Form 5000-41: Safety and Health Activity Certification (Mine Safety and Health Administration) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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30 CFR 75.100, 30 CFR 77.100 (Health and Safety Certification) establish the procedures under which miners are certified to make certain
tests and examinations which are required by MSHA regulations to be performed by certified persons. For mines located in states that do not
have provisions for certifying miners, 30 CFR 75.100 (c) (1) and 30 CFR 77.100 (b) (2) require mine operators to make application to MSHA to
obtain certification for miners who meet certain minimum experience requirements. A certified person is one who has been certified as a
Foreman, Asst. Forman (UG only), or Pre-shift Examiner (UG only).
30 CFR 75.155 and 30 CFR 77.105 (Hoisting Engineers Qualification) establish the procedures under which miners are qualified to operate
hoists (Steam Driven/Electrical-UG; Slope & Shaft Sinking Operation-Sur). For mines located in states that do not have provisions for qualifying
hoist operators, 30 CFR 75.155/77.105 require mine operators to make application to MSHA to obtain qualification for miners who meet certain
minimum experience requirements.
MSHA form 5000-41 provides all mine operators with a standard reporting format which expedites the certification and qualification process
while ensuring compliance with regulations. The information provided on the form enables MSHA to determine if miners satisfy the
requirements to obtain the certification/qualification sought.
This collection of information is covered by the Privacy Act notice published in the Federal Register. Computer safeguards are as described in
the National Bureau of Standards Publication, “Computer Security Guidelines for implementing the Privacy Act of 1974,” and in accordance with
procedures developed by MSHA under GSA Circular E-34.
Item 1. Company name and address,
if the address below is blank, information will be sent to the address selected in Item 4
Item 2. Mine ID
or
Contractor ID
Company Name
Attn:
Street 1
Street 2
City
State
ZIP
Item 7.
Certifications
Item 8.
Hoisting
Surface
Underground
Only
Hoisting
Only
Public reporting burden for this form is estimated to average 10 minutes per response for the electronic version and 17 minutes per response for the hard copy. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting 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, Paperwork Reduction Project (1219-0127).
,
Item 3. MSHA Individual Identification
Number (MIIN)
Item 4. Address Selector Item 5. Name (Last, First, M) Item 6. Miner Requested Send To Address
Foreman
Foreman
Assistant
Foreman
Pre-Shift
Examiner
Underground
Surface
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
MI
First
Attn:
Street 1
Street 2
City State Zip
MSHA FORM 5000-41 Revised Aug. 2015 (Mailing Address) Page 1 of 3
MSHA Form 5000-41: Safety and Health Activity Certification or
Hoisting Engineer Qualification Request
U.S. Department of Labor
Mine Safety and Health Administration
This form is affected by the Privacy Act of 1974
OMB Number 1219-0127. Expiration: 2/29/2024
1
2
3
Item 7.
Certifications
Item 8.
Hoisting
Surface
Underground
Only
Hoisting
Only
Return to:
MSHA, Qualification and Certification
P.O. Box 25367, DFC
Denver, CO. 80225
Item 3. MSHA Individual Identification
Number (MIIN)
Item 4. Address Selector Item 5 Name (Last, First, M) Item 6. Miner Requested Send To address
Foreman
Foreman
Assistant
Foreman
Pre-Shift
Examiner
Underground
Surface
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 6)
Last
First
MI
Attn:
Street 1
Street 2
City State Zip
I certify that the information in this application is correct and that each person
listed has had at least two years experience at a coal mine or equivalent experience and meets all
applicable requirements of section 75.100 and 77.100.
False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173
as amended by PL95-164)
Item 9. Type of Hoist: Electric Steam or Both
I certify that the persons listed are qualified to operate the type of hoist shown above, at a coal mine, that
they had a least one year experience associated with this type of hoisting equipment and successfully
operated a hoist at a mine for a period of six months immediately preceding this application
False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173
as amended by PL95-164)
Item 10
.
Signature for Activity Certification Request Item 11. Date Item 12. Signature for Hoisting Qualification Request Item 13. Date
Title Title
4
5
6
7
MSHA FORM 5000-41 Revised Aug. 2015 (Mailing Address) Page 2 of 3
Instructions for Completing MSHA Form 5000-41
Please Print Legibly
•
Item 1. Company Name and Address
The full name and address of the Company should be completely filled in. This is not required if the address selector in Item 4 is not
selected as Company Address.
•
Item 2. Mine ID or Contractor ID (Required)
The MSHA assigned MID or CID number must be filled in
•
Item 3. MSHA Individual Identification Number (MIIN) (Required)
The MIIN number is an MSHA assigned number that all individuals must obtain to be used for training submissions to MSHA and
also when contacting MSHA to verify records. If you need to obtain a MIIN please contact the Qualification and Certification Unit at
303-231-5472 or 800-579-2647.
•
Item 4. Address Selector, where the cards are to sent
o
If Mine Address is selected the address on file for the MID in Item 2 will receive the cards
o
If Contractor Address is selected the address on file for the MID in Item 2 will receive the cards.
o
If Company Address is selected Item 1 becomes required.
o
If Miner Requested Send to Address is selected Item 6 becomes required.
•
Item 5. Name (Required)
Last, First, Middle Initial of individual receiving the qualification or certification
•
Item 6. Miner Requested Send to Address
If the individual receiving training would like the qualification or certification card sent to a different address. Required if Miner Requested
Send to Address is selected in Item 4.
•
Item 7. Certifications (Required if request is for Activity Certification)
Choose the box designated for the type of certification requested
•
Item 8. Qualifications (Required if request is for Hoisting)
Choose the box designated for Hoisting Qualification requested
•
Item 9. Type of Hoist (Required if request is for Hoisting)
Choose the box designated for type of Hoist requested.
•
Item 10. Signature for Activity Certification Request (Required if request is for Activity Certification)
If a box in Item 7. is selected, the person requesting the individual be given Activity Certification needs to sign.
•
Item 11. Date (Required)
The date the Certification is being requested
•
Item 12. Signature for Hoisting Qualification (Required if request is for Hoisting Qualification)
If a box in Item 8 is selected, the person requesting the individual be given Hoisting Qualification needs to sign.
•
Item 13. Date (Required)
The date the Qualification is being requested
Return form to:
MSHA, Qualification and Certification
P.O. Box 25367
Denver, CO. 80225
Phone (303) 231-5472
Toll Free: (800) 579-2647
Fax: (303) 231-5474
Privacy Act Statement
30 CFR 75.100, 77.100, 75.155 and 77.105 authorize the collection of this information. This information will be used to
determine if miners satisfy the requirements to obtain the certification/qualification sought and for MSHA to maintain a record of
these certifications/qualifications. Submission of the items identified in the instructions as required is mandatory and failure to
submit the required information may delay or prevent action on the application.
MSHA FORM 5000-41 Revised Aug. 2015 (Mailing Address) Page 3 of 3
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MSHA Form 5000-41: Safety and Health Activity Certification (Mine Safety and Health Administration)

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Completed 25 September 2021

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