Safety and Health Activity Certification or Hoisting Engineer Qualification Request U.S. Department of Labor Mine Safety and Health Administration This form is affected by the Privacy Act of 1974 )RUP $SSURYHG 20% 1XPEHU  $SSURYDO ([SLUHV -XO\   Item 2. Mine ID or Contractor ID Item 1. Company name and address, if the address below is blank, information will be sent to the address selected in Item 4 Company Name 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, Asst. Forman (UG only), or Pre-shift Examiner (UG only). Attn: Street 1 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 require mine operators to make application to MSHA to obtain qualification for miners who meet certain minimum experience requirements. Street 2 City State Zip MSHA form 5000-41 provides all mine operators with a standard reporting format which expedites the certification and qualification process while ensuring compliance with regulations. The information provided on the form enables MSHA to determine if miners satisfy the requirements to obtain the certification/qualification sought. This collection of information is covered by the Privacy Act notice published in the Federal Register. Computer safeguards are as described in the National Bureau of Standards Publication, “Computer Security Guidelines for implementing the Privacy Act of 1974,” and in accordance with procedures developed by MSHA under GSA Circular E-34. 1 Mine Address (MSHA File) Contractor Address (MSHA File) Attn: Street 1 First Street 2 Company Address (Item 1) MIIN M, City Last Miner Requested Send to Address (Item 6) Attn: Mine Address (MSHA File) 2 Contractor Address (MSHA File) State Zip State Zip State Zip Street 1 First Street 2 Company Address (Item 1) MIIN 3 M, City Last Miner Requested Send to Address (Item 6) Attn: Mine Address (MSHA File) Contractor Address (MSHA File) Street 1 First Street 2 Company Address (Item 1) Miner Requested Send to Address (Item 6) M, MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 1 of 3 City Surface Surface Hoisting Only Underground Last Pre-Shift Examiner MIIN Item 6. Miner Requested Send To Address Assistant Foreman Item 5. Name (Last, First, M) Item 8. Hoisting Underground Only Foreman Item 3. MSHA Individual Identification Number (MIIN) Item 4. Address Selector Item 7. Certifications Foreman Public reporting burden for this collection of information is estimated to average 10 minutes per response IRU WKH HOHFWURQLF YHUVLRQ DQG  PLQXWHV IRU WKH SDSHU YHUVLRQ, LQFOXGLQJ WKH WLPH IRU reviewing LQVWUXFWLRQV VHDUFKLQJ H[LVWLQJ GDWD VRXUFHV JDWKHULQJ DQG PDLQWDLQLQJ WKH GDWD QHHGHG DQG FRPSOHWLQJ DQG UHYLHZLQJ WKH collection information 3HUVRQV DUH QRW UHTXLUHG WR UHVSRQG WR WKLV FROOHFWLRQ RI LQIRUPDWLRQ XQOHVV LW GLVSOD\V D FXUUHQW 20% &RQWURO 1XPEHU Send comments regarding this burden estimate or any other aspect of this collection of information LQFOXGLQJ VXJJHVWLRQV IRU UHGXFLQJ WKLV EXUGHQ WR: Records Management Branch Mine Safety and Health Administration 1100 Wilson Boulevard Arlington, VA. 22209-3939 Item 6. Miner Requested Send To address Attn: Mine Address (MSHA File) Contractor Address (MSHA File) Hoisting Only Surface Last Pre-Shift Examiner MIIN Assistant Foreman Item 5 Name (Last, First, M) Underground Only Foreman Foreman Item 3. MSHA Individual Identification Number (MIIN) Item 4. Address Selector 4 Surface Return to: MSHA, Qualification and Certification P.O. Box 25367, DFC Denver, CO. 80225 Item 8. Hoisting Underground Item 7. Certifications Street 1 First Street 2 Company Address (Item 1) MIIN M, City Last Miner Requested Send to Address (Item 6) Attn: Mine Address (MSHA File) 5 Contractor Address (MSHA File) State Zip State Zip Street 1 First Street 2 Company Address (Item 1) Miner Requested Send to Address (Item 6) City Last MIIN 6 M, Attn: Mine Address (MSHA File) Contractor Address (MSHA File) Street 1 First Street 2 Company Address (Item 1) MIIN M, City Last Miner Requested Send to Address (Item 6) Attn: Mine Address (MSHA File) 7 Contractor Address (MSHA File) State Zip Street 1 First Street 2 Company Address (Item 1) Miner Requested Send to Address (Item 6) M, City I certify that the information in this application is correct and that each person listed has had at least two years experience at a coal mine or equivalent experience and meets all applicable requirements of section 75.100 and 77.100. False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173 as amended by PL95-164) Item 9. Type of Hoist: Electric State Steam Zip or Both I certify that the persons listed are qualified to operate the type of hoist shown above, at a coal mine, that they had a least one year experience associated with this type of hoisting equipment and successfully operated a hoist at a mine for a period of six months immediately preceding this application False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173 as amended by PL95-164) Item 10. Signature for Activity Certification Request Item 11. Date Title MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 2 of 3 Item 12. Signature for Hoisting Qualification Request Item 13. Date Title American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing MSHA Form 5000-41 Please Print Legibly x Item 1. Company Name and Address The full name and address of the Company should be completely filled in. This is not required if the address selector in Item 4 is not selected as Company Address. x Item 2. Mine ID or Contractor ID (Required) The MSHA assigned MID or CID number must be filled in x Item 3. MSHA Individual Identification Number (MIIN) (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. x Item 4. Address Selector, where the cards are to sent o If Mine Address is selected the address on file for the MID in Item 2 will receive the cards o If Contractor Address is selected the address on file for the MID in Item 2 will receive the cards. o If Company Address is selected Item 1 becomes required. o If Miner Requested Send to Address is selected Item 6 becomes required. x Item 5. Name (Required) Last, First, Middle Initial of individual receiving the qualification or certification x Item 6. Miner Requested Send to Address If the individual receiving training would like the qualification or certification card sent to a different address. Required if Miner Requested Send to Address is selected in Item 4. x Item 7. Certifications (Required if request is for Activity Certification) Choose the box designated for the type of certification requested x Item 8. Qualifications (Required if request is for Hoisting) Choose the box designated for Hoisting Qualification requested x Item 9. Type of Hoist (Required if request is for Hoisting) Choose the box designated for type of Hoist requested. x Item 10. Signature for Activity Certification Request (Required if request is for Activity Certification) If a box in Item 7. is selected, the person requesting the individual be given Activity Certification needs to sign. x Item 11. Date (Required) The date the Certification is being requested x Item 12. Signature for Hoisting Qualification (Required if request is for Hoisting Qualification) If a box in Item 8 is selected, the person requesting the individual be given Hoisting Qualification needs to sign. x Item 13. Date (Required) The date the Qualification is being requested Return form to: MSHA, Qualification and Certification P.O. Box 25367 Denver, CO. 80225 Phone (303) 231-5472 Toll Free: (800) 579-2647 Fax: (303) 231-5474 Privacy Act Statement 30 CFR 75.100, 77.100, 75.155 and 77.105 authorize the collection of this information. This information will be used to determine if miners satisfy the requirements to obtain the certification/qualification sought and for MSHA to maintain a record of these certifications/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 application. MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com