Forms and Online Filings
Form number: |
MSHA Form 5000-41 |
Form name: |
Health Activity Certification or Hoisting Engineers
Qualification Request Form |
Description: |
All instructors are required to submit to MSHA the names of
persons who have satisfactorily completed required mine foreman and pre-shift
examiner or hoisting certification training. The 5000-41 is a combined version
of the previous 5000-4 and 5000-7 forms. MSHA uses the form information to
issue certification cards to qualified persons. |
OMB Control Number and Expiration Date: |
1219-0069; 7/31/2006 |
Filing Options: |
Form 5000-41, Health Activity Certification or Hoisting
Engineers Qualification Request Form can be either filed online or printed,
filled in and sent to MSHA according to the instructions below.
File
online Print, fill in and
mail or fax |
Filing Instructions: |
Detailed instructions for filing Form 5000-41, Health Activity
Certification or Hoisting Engineers Qualification Request Form are available in
HTML or
PDF.
If filing by mail or fax, completed printed forms should be sent
to:
MSHA Qualification and Certification P.O. Box
25367 Denver, Colorado 80225-0367 Fax: (303) 231-5474 |
Contact Information: |
Questions regarding this form should be directed to MSHA at
(877) 778-6055 or
zzMSHA-PEIRHelpDesk@dol.gov |
Privacy Notice: |
Privacy Notice |
Legal Authority: |
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, Assistant Foreman
(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 requires
mine operators to apply to MSHA to obtain qualification for miners who meet
certain minimum experience requirements. |
Burden Statement: |
Public reporting burden for this collection of information is
estimated to average 17 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection information. Persons
are not required to respond to this collection of information unless it
displays a currently valid OMB Control Number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of Information Management,
Department of Labor, Room N-1301, 200 Constitution Avenue, N.W., Washington, D.C.
20210; and to the Office of Management and Budget, Paperwork Reduction Project (1219-0069),
Washington, D.C. 20503. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number. |
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