Representative of Miners Designation Form U.S. Department of Labor
Mine Safety and Health Administration
Approved OMB Control Number 1219-0042, is approved for use through 12/31/2023
data sources, gathering and maintaining the date need, and completing and reviewing the collection of information. Persons are not required to respond to this collection
with provisions of the Freedom of Information Act (5 U.S.C. § 552); the Privacy Act (5 U.S.C. § 552a); and attendant regulations, 29 C.F.R. parts 70 and 71. Send comments
regarding this burden estimate or any other aspect of this collection of information. Including suggestions for reducing this burden, to: Office of Standards, Regulation and
Instructions for this form contain further information on the need and use of this form. A false or representation is punishable under Section 110(a) and (f) of the
Federal Mine Safety and Health Act, as amended (30 U.S.C. §820 (a) and (f)).
Variances, Mine Safety and Health Administration, 201 12th Street South, Suite 401, Arlington, VA 22202-5452. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.
of information of unless it displays a current OMB Control Number. The DOL offers no pledge of confidentiality in association with these information collections unless
Item 2 is checked and DOL will keep the miners' names and contact information confidential (Item 7) if Item 2 is checked. Section 103(f) and (g) of the Federal Mine Safety
and Health Act, as amended, (30 U.S.C. § 813(f) and (g)) and 43 FR 29508, 29509. As a practical matter, the DOL would only release this information in accordance
Item 1: Initial Filing Update Unknown
Item 2: Confidential
Item 3: Designation Type: Individual Organization
Representative Name: Title: ___________________
Address:
City: ___________________________ State: Zip Code
Telephone ( ) Email:
Item 4: Mine Operator's or Contractor's Name
Mine Address __________________________________
Mine MSHA ID No.:
Item 5: Scope of Designation: The person or position named as the representative of miners is the
representative for all purposes of the Act.
The representative’s authority is limited to: 101 (c)
103 (c)
Other
Item 6: Additional or Alternate Representatives:
1. Name: ______________________________________
Address:
City: ___________________________ State: Zip Code
Telephone: ( ___ ) _____ __________ Email: ____________________________________________
2. Name: ______________________________________
Address:
City: ___________________________ State: Zip Code
Telephone: ( ___ ) _____ __________ Email: ____________________________________________
Item 7. Designated By: (Name of two or more miners who work at the mine)
__________________________________ _______________________________
1 – Name: 2 – Name:
__________________________________ _______________________________
1 – Telephone: 2 – Telephone:
MSHA Form 2000-238, Aug. 2015 rev. (Mailing Address)
I certify that I have been designated as representative by at least two miners who work at the mine. I certify that all information being filed is
true and correct. A copy of this form has been delivered to the mine operator of the affected mine prior to or concurrently to the filing of this
statement.
Signed: _________________________________________________________ Date: ________________________________
Purpose: 30 CFR 40.3 authorizes a written declaration of any person or organization which represents two or more miners at a coal or other mine.
Public reporting burden for this collection of information estimated to average 45 minutes per response; including the time for reviewing instructions, searching existing
