2000-238 Representative of Miners' Designation Form

Representation of Miners Designation Form

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

Approved OMB Control Number 1219-0042, is approved for use through May 31, 2011
Purpose: 30 CFR 40.3 authorizes a written declaration of any person or organization which represents two or more miners at a coal or other mine.
Public reporting burden for this collection of information estimated to average 10 minutes per response; including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the date need, and completing and reviewing the collection of information. Send comments regarding the collection of
information, including suggestions for reducing this burden, to the Mine Safety & Health Administration, U.S. Department of Labor, Records Management Branch, 1100
Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently OMB Control Number.
The DOL offers no pledge of confidentiality in association with these information collections unless Item 2 is checked and DOL will keep the miners ' names and contact
information confidential (Item 7) if Item 2 is checked. Section 103(f) and (g) of the Federal Mine Safety and Health Act, as amended, (30 U.S.C. § 813(f) and (g)) and 43 FR
29508, 29509. As a practical matter, the DOL would only release this information in accordance with provisions of the Freedom of Information Act (5 U.S.C. § 552); the
Privacy Act (5 U.S.C. § 552a); and attendant regulations, 29 C.F.R. parts 70 and 71. 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. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. Instructions for this form contain further information on the need and use of this form. This is an
optional form. A false 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)).

Item 1:
Initial Filing
Item 2:
Confidential
Item 3: Designation Type:

Update
Individual

Representative Name:
Address:
City: ___________________________
Telephone (
)

Unknown
Organization
Title: ___________________
State:
Email:

Zip Code

Item 4: Mine Operator's or Contractor's Name
Mine Address __________________________________
Mine MSHA ID No.:
Item 5: Scope of Designation:

The person or position named as the representative of miners is the
representative for all purposes of the Act.
The representative’s authority is limited to:

101 (c)
103 (c)
Other

Item 6: Additional or Alternate Representatives:
1.

Name: ______________________________________
Address:
City: ___________________________
State:
Zip Code
Telephone: ( ___ ) _____ __________
Email: ____________________________________________

2.

Name: ______________________________________
Address:
City: ___________________________
State:
Zip Code
Telephone: ( ___ ) _____ __________
Email: ____________________________________________

Item 7. Designated By: (Name of two or more miners who work at the mine)

__________________________________

_______________________________

__________________________________

_______________________________

1 – Name:

1 – Telephone:

2 – Name:

2 – Telephone:

I certify that I have been designated as representative by at least two miners who work at the mine. I certify that all information being filed is
true and correct. A copy of this form has been delivered to the mine operator of the affected mine prior to or concurrently to the filing of this
statement.
Signed: _________________________________________________________

MSHA Form 2000-238, April 2011

Date: ________________________________

Instructions for Completing MSHA Form 2000-238
This form is a written declaration of any person or organization which represents two or more miners at a coal or other
mine for the purposes of the Act. The use of this form is voluntary in complying with 30 C.F.R. § 40.3.
Item 1. Type of filing.
Check the box "initial filing" if a mine operator has not had a miners' representative designated under
30 C.F.R. Part 40 or the appropriate information under Part 40 was not submitted to MSHA. For all other
filings with MSHA concerning a miners' representative designation, check the "Updates" box. If the miners'
representative is uncertain about the type of filing, check the box "Unknown." This box should be used
sparingly.
Item 2. Confidential Designation.
This item is completed only if the two miners who are designating the individual or entity as their miners'
representative want their identities to remain confidential, i.e., an anonymous designation. Check the box if
the miners want a confidential designation.
Item 3. Designation. (REQUIRED).
This item must be completed. Provide the name and other information identified in Item 3 for the individual
or the organization (and the title of the position of the representative in the organization) that the two miners
have designated under Part 40.
Item 4. Mine Operator's or Contractor's Name and ID. (REQUIRED).
The name of the mine operator or contractor is required to identify the mine that the miners have designated
this representative for the purposes provided in the Federal Mine Safety and Health Act of 1977 (Mine Act).
The MSHA assigned Mine ID or Contractor ID number must be filled in to verify that MSHA has the correct
mine for this representative.
Item 5. Scope of Designation.
Miners' representative may serve for all or selected purposes under the Mine Act. Check the appropriate
box for the miners' representative designated in Item 3. If the section of the Mine Act is not identified, check
the "other" box and fill in the information provided on the form.
Item 6. Additional or Alternate Representatives.
Check the box if you are providing any additional or alternate representatives. If you are providing more
than two, you may print out this form and add as many representatives on a supplemental page and mail the
form to the appropriate Coal or Metal and Nonmetal Safety and Health District Manager.
Item 7. Designated By. (REQUIRED).
Item 7 is required to be completed. It Item 2 is checked, then the information in Item 7 will be kept
confidential.
Privacy Act Statement
30 C.F.R. § 40.3 authorizes the collection of this information. This information will be used by MSHA inspectors to
contact the miners' representative once the inspector is at the mine before conducting an inspection. This information
also permits MSHA to verify that miners' representative was designated by two miners who work at the mine. This is
very important for confidential or anonymous designations. Section 103(f) and (g) of the Mine Act, (30 U.S.C. § 813(f)
and (g)) and 43 FR 29508, 29509. Submission of the items identified in the instructions as required is mandatory and
failure to submit the required information may delay MSHA ability to verify the designation of the miners' representative
and delay the miners' representative participating in inspection activities at the mine.