U.S. Department of Labor Mine Safety and Health Administration Certificate of Training MSHA Form 5000-23, Jan. 99 (revised) Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. This is a mandatory collection of information as required by 30 CFR Part 48.9 and 48.29. The information provides MSHA with a monitoring tool for determining compliance requirements. The Certificate of Training provides a means for operators to record and certify mandatory training received by miners. Send comments regarding the collection of information, including suggestions for reducing this burden to the Mine Safety and Health Administration, Department of Labor, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE American LegalNet, Inc. www.FormsWorkFlow.com U.S. Department of Labor Certificate of Training Mine Safety and Health Administration Approved OMB Number 1219-0009, Expires July 31, 2014. This certificate is required under Public Law 91-173 as amended by Public Law 95-164. Failure to comply may result in penalties and other sanctions as provided by sections 108 and 110, Public Law 91-173 as amended by Public Law 95-164. Serial Number (for operator’s use) Issue Certificate Immediately Upon Completion of Training 1. Print Full Name of Person Trained (first, middle, last) 2. Check Type of Approved Training Received: Annual Experienced Miner Refresher Newly Employed New Task Inexperienced Miner (specify below) Date Task Hazard Training Other (specify) Date Initials Task Initials Instr Instr Studt Studt 3. Check Type of Operation and Related Industry: A. Surface Construction B. Coal Metal Underground Shaft & Slope Nonmetal 4. Date Training Requirements Completed Check if not completed and go to item 5, below. If completed, go to item 6, below. 5. Check Subjects Completed (Use only for partially completed training): Introduction to Work Environment Roof/Ground Control & Ventilation Hazard Recognition Emergency Medical Procedures Mine Map; Escapeways; Emergency Evacuation; Barricading First Aid H&S Aspects of Tasks Assigned Cleanup; Rock Dusting Mine Gases Statutory Rights of Miners Mandatory Health & Safety Standards Explosives Self-Rescue & Respiratory Devices Transport & Communications Systems 6. False certification is punishable under section 110 (a) and (f) of the Federal Mine Safety & Health Act (P. L. 91-173 as amended by P. L. 95-164). Authority & Responsibility of Supervisors & Miners Representatives Health ElectricalHazards Prevention of Accidents Other (specify) I certify that the above training has been completed (signature of person responsible for training) 7. Mine Name, ID, & Location of Training (if institution, give name & address) 8. Date I verify that I have completed the above training (signature of person trained) MSHA Form 5000-23, Jan. 99 (revised) American LegalNet, Inc. www.FormsWorkFlow.com