Form 5000-41 Safety & Health Activity Certification or Hoisting Engin

Safety and Health Activity Certification or
Hoisting Engineer Qualification Request

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

This form is affected by the Privacy Act of 1974

Form Approved: OMB Number 1219-0127 Approval Expires May 31, 2011

Item 2. Mine ID or Contractor ID

Item 1. Company name and address, if the address below is blank, information will be sent to the address selected in Item 4
Company Name

30 CFR 75.100, 30 CFR 77.100 (Health and Safety Certification) establish the procedures under which miners are certified to make certain
tests and examinations which are required by MSHA regulations to be performed by certified persons. For mines located in states that do not
have provisions for certifying miners, 30 CFR 75.100 (c) (1) and 30 CFR 77.100 (b) (2) require mine operators to make application to MSHA to
obtain certification for miners who meet certain minimum experience requirements. A certified person is one who has been certified as a
Foreman, Asst. Forman (UG only), or Pre-shift Examiner (UG only).

Attn:
Street 1

30 CFR 75.155 and 30 CFR 77.105 (Hoisting Engineers Qualification) establish the procedures under which miners are qualified to operate
hoists (Steam Driven/Electrical-UG; Slope & Shaft Sinking Operation-Sur). For mines located in states that do not have provisions for qualifying
hoist operators, 30 CFR 75.155/77.105 require mine operators to make application to MSHA to obtain qualification for miners who meet certain
minimum experience requirements.

Street 2
City

State

Zip

MSHA form 5000-41 provides all mine operators with a standard reporting format which expedites the certification and qualification process
while ensuring compliance with regulations. The information provided on the form enables MSHA to determine if miners satisfy the
requirements to obtain the certification/qualification sought.
This collection of information is covered by the Privacy Act notice published in the Federal Register. Computer safeguards are as described in
the National Bureau of Standards Publication, “Computer Security Guidelines for implementing the Privacy Act of 1974,” and in accordance with
procedures developed by MSHA under GSA Circular E-34.

Last

MIIN
1

Mine Address (MSHA File)
Contractor Address (MSHA File)

Attn:
Street 1

First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)
MIIN

MI

City

Last

Attn:

Mine Address (MSHA File)

2

Contractor Address (MSHA File)

State

Zip

State

Zip

State

Zip

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)
MIIN
3

MI

City

Last

Attn:

Mine Address (MSHA File)
Contractor Address (MSHA File)

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)

MI

MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 1 of 3

City

Surface

Surface

Hoisting
Only
Underground

Pre-Shift
Examiner

Item 6. Miner Requested Send To Address

Assistant
Foreman

Item 5. Name (Last, First, M)

Item 8.
Hoisting

Underground
Only
Foreman

Item 3. MSHA Individual Identification
Number (MIIN)
Item 4. Address Selector

Item 7.
Certifications

Foreman

Public reporting burden for this collection of information is estimated to average 10 minutes per response for the electronic version and 17 minutes for the paper version, 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 current 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

Item 6. Miner Requested Send To address
Attn:

Mine Address (MSHA File)
Contractor Address (MSHA File)

Hoisting
Only

Surface

Last

Pre-Shift
Examiner

MIIN

Assistant
Foreman

Item 5 Name (Last, First, M)

Underground
Only

Foreman

Foreman

Item 3. MSHA Individual Identification
Number (MIIN)
Item 4. Address Selector

4

Surface

Return to:
MSHA, Qualification and Certification
P.O. Box 25367, DFC
Denver, CO. 80225

Item 8.
Hoisting

Underground

Item 7.
Certifications

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)
MIIN

MI

City

Last

Attn:

Mine Address (MSHA File)

5

Contractor Address (MSHA File)

State

Zip

State

Zip

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)

City

Last

MIIN
6

MI

Attn:

Mine Address (MSHA File)
Contractor Address (MSHA File)

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)
MIIN

MI

City

Last

Attn:

Mine Address (MSHA File)

7

Contractor Address (MSHA File)

State

Zip

Street 1
First
Street 2

Company Address (Item 1)
Miner Requested Send to Address (Item 6)

MI

City

I certify that the information in this application is correct and that each person
listed has had at least two years experience at a coal mine or equivalent experience and meets all
applicable requirements of section 75.100 and 77.100.
False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173
as amended by PL95-164)

Item 9. Type of Hoist: Electric

State
Steam

Zip
or Both

I certify that the persons listed are qualified to operate the type of hoist shown above, at a coal mine, that
they had a least one year experience associated with this type of hoisting equipment and successfully
operated a hoist at a mine for a period of six months immediately preceding this application
False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL 91-173
as amended by PL95-164)

Item 10. Signature for Activity Certification Request

Item 11. Date

Title
MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 2 of 3

Item 12. Signature for Hoisting Qualification Request
Title

Item 13. Date

Instructions for Completing MSHA Form 5000-41
Please Print Legibly
•

Item 1. Company Name and Address
The full name and address of the Company should be completely filled in. This is not required if the address selector in Item 4 is not
selected as Company Address.

•

Item 2. Mine ID or Contractor ID (Required)
The MSHA assigned MID or CID number must be filled in

•

Item 3. MSHA Individual Identification Number (MIIN) (Required)
The MIIN number is an MSHA assigned number that all individuals must obtain to be used for training submissions to MSHA and
also when contacting MSHA to verify records. If you need to obtain a MIIN please contact the Qualification and Certification Unit at
303-231-5472 or 800-579-2647.

•

Item 4. Address Selector, where the cards are to sent
o
If Mine Address is selected the address on file for the MID in Item 2 will receive the cards
o
If Contractor Address is selected the address on file for the MID in Item 2 will receive the cards.
o
If Company Address is selected Item 1 becomes required.
o
If Miner Requested Send to Address is selected Item 6 becomes required.

•

Item 5. Name (Required)
Last, First, Middle Initial of individual receiving the qualification or certification

•

Item 6. Miner Requested Send to Address
If the individual receiving training would like the qualification or certification card sent to a different address. Required if Miner Requested
Send to Address is selected in Item 4.

•

Item 7. Certifications (Required if request is for Activity Certification)
Choose the box designated for the type of certification requested

•

Item 8. Qualifications (Required if request is for Hoisting)
Choose the box designated for Hoisting Qualification requested

•

Item 9. Type of Hoist (Required if request is for Hoisting)
Choose the box designated for type of Hoist requested.

•

Item 10. Signature for Activity Certification Request (Required if request is for Activity Certification)
If a box in Item 7. is selected, the person requesting the individual be given Activity Certification needs to sign.

•

Item 11. Date (Required)
The date the Certification is being requested

•

Item 12. Signature for Hoisting Qualification (Required if request is for Hoisting Qualification)
If a box in Item 8 is selected, the person requesting the individual be given Hoisting Qualification needs to sign.

•

Item 13. Date (Required)
The date the Qualification is being requested
Return form to:
MSHA, Qualification and Certification
P.O. Box 25367
Denver, CO. 80225
Phone (303) 231-5472
Toll Free: (800) 579-2647
Fax: (303) 231-5474

Privacy Act Statement
30 CFR 75.100, 77.100, 75.155 and 77.105 authorize the collection of this information. This information will be used to
determine if miners satisfy the requirements to obtain the certification/qualification sought and for MSHA to maintain a record of
these certifications/qualifications. Submission of the items identified in the instructions as required is mandatory and failure to
submit the required information may delay or prevent action on the application.

MSHA FORM 5000-41 Revised January 2008 (Previous Versions Obsolete) Page 3 of 3