MSHA 2000-222 SCSR Inventory and Report

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3) Out of Date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)