Instructions for Completing MSHA Form 5000-1
Item 1. Company Name and Address
If in Item 8 on the form,
Company Address
is selected the full name and address of the company is required. This will be the address used to
mail the Electrical Qualification cards.
Item 2. Mine ID or Contractor ID
The MSHA assigned MID or CID number may be filled in. This number was assigned by MSHA. If in Item 8
Mine Address
or
Contractor
Address
is selected then this becomes a required field. MSHA is no longer using miscellaneous Mine Id’s or Contractor ID’s example: XX-
77003 and XX-77004
Item 3. Instructor’s Name (REQUIRED)
Provide the Last Name, First Name of the instructor who gave the electrical training
Item 4. Instructor’s MSHA Individual Identification Number (MIIIN) (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 5. Name of the County and State Where Training Took Place (REQUIRED)
County and State is required to provide information to the appropriate district if the MID or CID is not used.
Item 6. AR/ROE No. (Required if training provided by MSHA or MSHA is reinstating the qualification)
This field is MSHA use only.
Item 7. Date Training Completed (REQUIRED)
The date the training was completed
Item 8. Individual Receiving Training MSHA Individual Identification Number (MIIN)
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.
Choice Where to Mail Cards (REQUIRED)
If Mine Address is selected Item 2 becomes Required.
If Contractor Address is selected Item 2 becomes Required.
If Company Address is selected Item 1 becomes Required.
If Miner Requested Send to Address is selected Item 10 becomes Required.
Item 9. Name (REQUIRED)
The Last Name, First Name, Middle Initial of the individual receiving training
Item 10. Miners Requested Send To Address
If the individual receiving training would like the Electrical Qualification Cards sent to a different address.
Required if Miner requested Send to Address is selected in Item 8.
Item 11. Electrical Codes (Some or all codes are REQUIRED)
These check boxes should be used to indicate which training the individual received.
EB – Initial Underground Training
ED – Initial Surface Training
EC – Retraining Underground
EE – Retraining Surface
Item 12. MSHA Use Only [codes]
Only MSHA personnel may use these codes. RU, RS codes are now used to reinstate Electrical Qualifications. An AR/ROE number is
required in Item 6 to process these codes.
RU – Reinstatement Underground
RS – Reinstatement Surface
Item 13. Signature of Instructor (REQUIRED)
The signature of the Instructor mentioned in Item 3 must appear here to “Certify that the above individuals have completed the course(s)
indicated.”
Return to:
MSHA, Qualification & Certification
P.O. Box 25367, DFC
Denver, CO. 80225
Phone (303) 231-5472
Toll Free (800) 579-2647
Fax (303) 231-5474
Privacy Act Statement
30 CFR 75.153, and 77.103 authorize the collection of this information. This information will be used to determine if miners satisfy the requirements to
obtain the certifications/qualifications sought and for MSHA to maintain records of these 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 applications.
MSHA Form 5000-1 Page 3 of 3
