Form MSHA-5000-23 Certificate of Training

U.S. Department of Labor
Mine Safety and Health Administration

Certificate of Training
MSHA Form 5000-23, Jan. 03 (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

Certificate of Training

U.S. Department of Labor
Mine Safety and Health Administration

Approved OMB Number 1219-0009, Expires Month, Day, Year.

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.
Serial Number (for operator’s use)

Issue Certificate Immediately
Upon Completion of Training

1. Print Full Name of Person Trained (first, middle, last)
2. Check Type of Approved Training Received:
Annual

Experienced Miner
Refresher
New Task
Newly Employed,

(specify below)

Inexperienced Miner
Date
Task
Date
Initials
Instr

Hazard Training
Other (specify)
Task

Initials
Instr

Studt

Studt

3. Check Type of Operation and Related Industry:

A.
B.

Construction
Surface
Metal
Coal
4. Date Training Requirements Completed

Underground

Shaft & Slope

Nonmetal
Check if not completed
and go to item 5, below.

If completed, go to item 6, below.
5. Check Subjects Completed (use only for partially completed training):
Roof/Ground Control
Introduction to Work Environment

& Ventilation

Hazard Recognition

Mine Map; Escapeways;
Emergency Evacuation;
Emergency Medical Procedures
Barricading
H&S Aspects of Tasks Assigned

Cleanup; Rock Dusting

Statutory Rights of Miners

Mandatory Health &
Safety Standards

Self-Rescue & Respiratory Devices
Transport & Communication Systems
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).

Authority & Responsibility
of Supervisors & Miners’
Representatives

Health

Electrical Hazards
First Aid
Mine Gases
Explosives
Prevention of Accidents
Other (specify)

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)

Clear Form