Form number:

MSHA Form 5000-3

Form name:

Certificate of Physical Qualification for Mine Rescue Work

Description:

Title 30, CFR § 49 requires the mine operator of an underground mine to establish at least two mine rescue teams to be available at all times that miners are underground, or the operator must enter into an arrangement for mine rescue services which assures that at least two teams are available at all times when miners are underground.

Under Title 30, CFR § 49.7, each mine rescue team member must be examined by a physician annually, with the first examination being completed within 60 days prior to scheduled initial training. An MSHA Form 5000-3 for each team member must be completed and signed by the examining physician. These forms shall be kept on file at the mine rescue station for a period of one year.

OMB Control Number and Expiration Date:

1219-0078; 1/31/2010

Filing Options:

Form 5000-3 may be completed while on your PC screen, printed (or printed and filled in manually) and sent to MSHA according to the instructions provided below. This is not the same as on-line filing.

Fill in, print and mail or fax

Contact Information:

Questions regarding this form should be directed to MSHA at (877) 778-6055 or MSHAhelpdesk@dol.gov

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 49.7

Burden Statement:

Public reporting burden for this collection of information is estimated to average 32 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data need, and completing and reviewing the collection of information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety and Health Administration, U.S. Department of Labor, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.