Certificate Of Physical Qualification For Mine Rescue Work {MSHA 5000-3} | Pdf Fpdf Doc Docx | Official Federal Forms

Certificate Of Physical Qualification For Mine Rescue Work {MSHA 5000-3}

Official Federal Forms/US Dept Of Labor/
Certificate Of Physical Qualification For Mine Rescue Work {MSHA 5000-3} | Pdf Fpdf Doc Docx | Official Federal Forms

Certificate Of Physical Qualification For Mine Rescue Work Form

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This is a Official Federal Forms form that can be used for US Dept Of Labor.

Last updated: 5/2/2006
Certificate of Physical Qualification U.S. Department of Labor for Mine Rescue Work Mine Safety and Health Administration O.M.B. Number 1219-0078, Approval Expires 01/31/2007 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, gather ing 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, Rec ords Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Special Requirements: 1. Authority: 30 CFR 49.7 Physical Requirements for Mine Rescue Team Members and Alter nates, and Executive Order 12044. 2. Principal Purpose: To provide a routine check of miners physical condition to wear oxygen breathing apparatus in mine rescue work. 3. Routine Uses: Certification is made by a physician and kept for one year at the mine r escue station. Completion of form requires only that examining physician list name and address of miner and employer and cert ify that the proper examination has been made. Physical findings need not be listed on this form. 4. Disclosure is Mandatory: Without such information, miner cannot be considered for mine rescue wor k. 1. Individuals Name 2. Address (City, State, and Zip Code) 3. Employers Name 4. Address (City, State, and Zip Code) 5. Note: 30 CFR 49.7(c) states that the physician shall take the following cond itions into consideration: (a) Seizure disorder; (b) Perforated eardrum; (c) Hearing loss without a hearing aid greater than 40 decibels at 400, 1,00 0 and 2,000 Hz; (d) Repeated blood pressure (controlled or uncontrolled by medication) rea ding which exceeds 160 systolic, or 100 diastolic, or which is less than 105 systolic, or 60 diastolic; (e) Distant visual acuity (without glasses) less than 20/50 Snellen scale in one eye, and 20/70 in the other; (f) Heart disease; (g) Hernia; (h) Absence of a limb or hand; or (i) Any other condition which the examining physician determines is relevant to the question of whether the miner is fit for rescue team service. I certify that I have examined the individual listed above, and determin ed that he/she is physically fit to perform mine rescue and recovery work for prolonged periods under strenuous condition s. 6. Physicians Signature 7. Date 8. Physicians Address (City, State, and Zip Code) MSHA Form 5000-3, July 96 (revised) DRAFT American LegalNet, Inc. www.USCourtForms.com