Information Collection

Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons

IC 14446 under ICR 200912-1219-003 · OMB 1219-0078.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0078 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5000-3 Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons	Form and Instruction
5000-3 Certificate of Physical Qualification for Mine Rescue Wo Form 5000-3 Cert of Physical Quals.pdf www.msha.gov/forms/5000-3.pdf	Form and Instruction

IC Title:

Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.9 30 CFR 49.3 30 CFR 49.2 30 CFR 49.4 30 CFR 49.6 30 CFR 49.8 30 CFR 49.7 30 CFR 49.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5000-3	Certificate of Physical Qualification for Mine Rescue Work	Form 5000-3 Cert of Physical Quals.pdf	http://www.msha.gov/forms/5000-3.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 224

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16,873	-28,397	45,270
Annual IC Time Burden (Hours)	8,825	-15,540	24,365
Annual IC Cost Burden (Dollars)	243,049	-405,147	648,196

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.