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Certificate Of Training MSHA 5000-23 - Official Federal Forms
| Certificate Of Training Form. This is a national form and can be used in US Dept Of Labor . |
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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 Certificate of Training U.S. Department of Labor 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. Issue Certificate Immediately Upon Completion of Training 1. Print Full Name of Person Trained (first, middle, last) Serial Number (for operator's use) 2. Check Type of Approved Training Received: Annual Experienced Miner Refresher Newly Employed New Task Inexperienced Miner (specify below) Date Task Initials Instr Studt Hazard Training Other (specify) Task Initials Instr Studt Date 3. Check Type of Operation and Related Industry: A. Surface Construction Underground Nonmetal Shaft & Slope B. Coal Metal 4. Date Training Requirements Completed If completed, go to item 6, below. Check if not completed and go to item 5, below. 5. Check Subjects Completed (Use only for partially completed training): Introduction to Work Environment Hazard Recognition Emergency Medical Procedures H&S Aspects of Tasks Assigned Statutory Rights of Miners Self-Rescue & Respiratory Devices Transport & Communications Systems Roof/Ground Control & Ventilation Mine Map; Escapeways; Emergency Evacuation; Barricading Cleanup; Rock Dusting Mandatory Health & Safety Standards Authority & Responsibility of Supervisors & Miners Representatives Health ElectricalHazards First Aid Mine Gases Explosives Prevention of Accidents Other (specify) 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). 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
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