Health Activity Certification Or Hoisting Engineer Qualification Request Form {MSHA 500-41} | Pdf Fpdf Doc Docx | Official Federal Forms

Health Activity Certification Or Hoisting Engineer Qualification Request Form {MSHA 500-41}

Health Activity Certification Or Hoisting Engineer Qualification Request Form {MSHA 500-41} | Pdf Fpdf Doc Docx | Official Federal Forms

Health Activity Certification Or Hoisting Engineer Qualification Request Form Form

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

Last updated: 11/24/2008
Safety and Health Activity Certification or Hoisting Engineer Qualification Request This form is affected by the Privacy Act of 1974 U.S. Department of Labor Mine Safety and Health Administration Form Approved: OMB Number 1219-0127 Approval Expires April 30, 2011 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 Attn: Street 1 Street 2 City State Zip Item 2. Mine ID or Contractor ID 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). 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. 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. Public reporting burden for this collection of information is estimated to average 10 minutes per response for the electronic version and 17 minutes for the paper version, 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 current 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 Item 7. Certifications Surface Item 8. Hoisting Underground Only Pre-Shift Examiner Assistant Foreman Foreman Hoisting Only Underground Surface Item 3. MSHA Individual Identification Number (MIIN) Item 4. Address Selector MIIN 1 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) MIIN 2 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) MIIN 3 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) Item 5. Name (Last, First, M) Last Item 6. Miner Requested Send To Address Attn: Street 1 First Street 2 MI City State Zip Last Attn: Street 1 First Street 2 MI City State Zip Last Attn: Street 1 First Street 2 MI City State Zip American LegalNet, Inc. www.FormsWorkflow.com MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 1 of 3 Foreman Item 7. Certifications Item 8. Hoisting Return to: MSHA, Qualification and Certification P.O. Box 25367, DFC Denver, CO. 80225 Surface Underground Only Hoisting Only Underground Pre-Shift Examiner Assistant Foreman Foreman Foreman Item 3. MSHA Individual Identification Number (MIIN) Item 4. Address Selector MIIN 4 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) MIIN 5 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) MIIN 6 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) MIIN 7 Mine Address (MSHA File) Contractor Address (MSHA File) Company Address (Item 1) Miner Requested Send to Address (Item 6) Item 5 Name (Last, First, M) Last Item 6. Miner Requested Send To address Attn: Street 1 First Street 2 MI City State Zip Last Attn: Street 1 First Street 2 MI Last City Attn: Street 1 First Street 2 MI City State Zip State Zip Last Attn: Street 1 First Street 2 MI City Item 9. Type of Hoist: Electric State Steam Zip or Both 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) 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 Title Item 11. Date Item 12. Signature for Hoisting Qualification Request Title Item 13. Date MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Surface Instructions for Completing MSHA Form 5000-41 Please Print Legibly · 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. Item 2. Mine ID or Contractor ID (Required) The MSHA a