SCSR Inventory and REPORT OMB #1219-0141 Expires 3/31/2010 INSTRUCTIONS: This form is for Operators’ use in providing MSHA with complete SCSR inventories as well as in reporting problems with SCSRs. Operators may attach continuation sheets to this form provided all required SCSR information is included. Enter date information is being reported, MSHA- issued mine ID, name mine is operating under, company name, address of mine, contact name and telephone number. Select the manufacturer/model, enter date of manufacture, serial number and report date. If “Other MSHA-approved SCSR ____” is selected, write in the manufacturer/model. The use of this form is voluntary in complying with 75.1714-8. Report Date:____________________ E-mail:____________________ Mine ID: __________________ (MSHA Mine ID) Mine Name: ______________________________________ Company Name:__________________________ Address: __________________________________________ (Street, P.O.) _________________________________________________ City State Zip Contact name: __________________________ Telephone: ____________ Manufacturer/Model Date of Manufacture  CSE SR-100 _________________  OCENCO EBA 6.5 _________________  OCENCO M20 _________________  DRAEGER OXY-K Plus ________________  DRAEGER OXY-K Plus S _________________  MSA LIFE-SAVER 60 _________________  Other MSHA-approved SCSR_______ _________________ Serial Number In/Out Reason ____________ ____________ ____________ ____________ ____________ ____________ ____________        ________ ________ ________ ________ ________ ________ ________ If reporting an SCSR out of inventory, identify the SCSR and enter reason number above: 1) Out for Refurbishment 4) Missing 2) Damaged/Not Repairable 5) Transferred 3) Out of Date 6) Used/Activated Send this form to: Mine Safety and Health Administration Technical Support Pittsburgh Safety and Health Technology Center Attn: SCSR Coordinator Cochrans Mill Road P.O. Box 18233 Pittsburgh, Pennsylvania 15236 A false statement or representation is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act, as amended (30 U.S.C. § 820(a) and (f)). Privacy Notice: The report is used to establish a database containing information about each self-contained self-rescuer for each mine. Any personal information (e-mail or otherwise) submitted is used for contact purposes only. This information will be used only by federal government agencies and will not be distributed to the public. Purpose: 30 CFR 75.1714-8 authorizes the collection of this information. MSHA maintains an inventory of all reported SCSR information to assure the effectiveness of evacuation plans and emergency evacuations. In addition, such an inventory will assist in targeting SCSR recalls to specific mines. The use of this form will facilitate SCSR inventory information transfer from mine operators to MSHA. MSHA may not sponsor or endorse products. Burden Statement: Public reporting burden for this collection of information is estimated from 3 hours to 19 hours depending on the size of the mine 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: Records Management Branch, Mine Safety and Health Administration, 1100 Wilson Boulevard, Arlington, VA 22209-3939. MSHA Form 2000-222 (February 2007) American LegalNet, Inc. www.FormsWorkflow.com