MSHA Form 2000-224, Operator's Annual Certification of Mine Rescue Team Qualifications

Form Approved OMB No. 1219-0144
Expires: May 31, 2010

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

Operator's Annual Certification of Mine Rescue Team Qualifications

Instructions: 30 CFR Part 49 Subpart B requires the mine operator to certify annually that each of the two mine rescue teams designated to provide mine rescue coverage for this underground coal
mine meets the requirements of this subpart. To use this optional form for the annual certification statement, fill-in information indicated in each box. Check the circle to indicate a "yes" response. Print or
make a copy of the completed form for your records. Sign, date and send the form to the appropriate MSHA District Manager.
Page 1 of 2
Company Name:

Contractor ID No.

MSHA Mine ID No.
Mine Name:

Mine size:

Team Name:

Type of Team:

Large
Mine-site

Team is available at all times when miners are
underground

Small
Composite

Mine Rescue Team is available within 1-hour ground travel time from the Mine Rescue Station

Contract

State-sponsored

Appropriate mine rescue equipment is provided,
inspected, tested, and maintained

Address of Mine Rescue Station:
1

2

3

4

5

Alternate

New member training

Initial 20 hrs.

Initial 20 hrs.

Initial 20 hrs.

Initial 20 hrs.

Initial 20 hrs.

Initial 20 hrs.

Annual training

Refresher training
totals 96 hrs. or more

Refresher training
totals 96 hrs. or more

Member's name

Employer's name

Experience working in
underground coal mine
Physically fit

8 hrs. training every 2 mos;
incudes wearing apparatus
for 2 hrs.

Refresher training
totals 96 hrs. or more

Refresher training
totals 96 hrs. or more

Refresher training
totals 96 hrs. or more

Refresher training
totals 96 hrs. or more

Jan-Feb

Jan-Feb

Jan-Feb

Jan-Feb

Jan-Feb

Mar-Apr

Mar-Apr

Mar-Apr

Mar-Apr

Mar-Apr

Mar-Apr

May-Jun
Jul-Aug

May-Jun
Jul-Aug

May-Jun
Jul-Aug

May-Jun
Jul-Aug

May-Jun
Jul-Aug

May-Jun
Jul-Aug

Sep-Oct
Nov-Dec

Sep-Oct
Nov-Dec

Sep-Oct
Nov-Dec

Sep-Oct
Nov-Dec

Sep-Oct
Nov-Dec

Sep-Oct
Nov-Dec

Jan-Feb

MSHA Form 2000-224 (Rev. 2010)
(previous versions are usable)

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

Operator's Annual Certification of Mine Rescue Team Qualifications

Page 2 of 2
Trains underground every
6 mos.

Jan-Feb

Jan-Feb

Jan-Feb

Jan-Feb

Jan-Feb

Jan-Feb

Jul-Dec

Jul-Dec

Jul-Dec

Jul-Dec

Jul-Dec

Jul-Dec

Wears apparatus in
smoke annually
Familiar with operations
of mine
Knowledge of operations
& ventilation of mine

Participates in two local
mine rescue contests
(insert dates)

Trains at this mine (insert
dates)

I certify the information above is ture and accurate to the best of my knowledge.
Position held at the mine:

Printed Name

Date:

Signature

Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. Responses
to the collection of information are mandatory whereas 30 CFR § 49.50 requires mine operators to certify the qualifications of mine rescue teams. MSHA developed this form as an optional-use compliance
tool to ease the burden of complying with 30 CFR Part 49 Subpart B. MSHA offers no pledge of confidentiality in association with this information collection. As a practical matter, MSHA would only
release this information in accordance with the provisions of the Freedom of Information Act (5 U.S.C. § 552) or as otherwise required by law. The time required to complete this form is estimated to
average 31 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestion for reducing this burden, to the Office of information Management,
Department of Labor, Room N-1301, 200 Constitution Avenue, N.W., Washington, D.C. 20210. PLEASE DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.
MSHA Form 2000-224 (Rev. 2010)
(previous versions are usable)

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