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Mine Safety and Health
Administration - MSHA
- Protecting Miners' Safety
and Health Since 1978

Form number:

MSHA Form 5000-3

Form name:

Certificate of Physical Qualification for Mine
Rescue Work

Description:

Title
30, CFR § 49 requires the mine operator of an underground mine
to establish at least two mine rescue teams to be available at all
times that miners are underground, or the operator must enter into
an arrangement for mine rescue services which assures that at least
two teams are available at all times when miners are underground.

Under Title 30, CFR ï¿½ 49.7, each mine
rescue team member must be examined by a physician annually, with
the first examination being completed within 60 days prior to
scheduled initial training. An MSHA Form 5000-3 for each team member
must be completed and signed by the examining physician. These forms
shall be kept on file at the mine rescue station for a period of one
year.

OMB Control Number and
Expiration Date:

1219-0078; Approval Expires 2/28/2013

Filing Options:

Form 5000-3 should be printed and filled in manually.
This form must be completed and signed by the examining physician
for each member of a mine rescue team. These forms shall be kept on
file at the mine rescue station for a period of 1 year.

Get Form

Contact Information:

Questions regarding this form
should be directed to MSHA at
(877) 778-6055 or [email-masked]

Privacy Notice:

Privacy
Notice

Legal Authority:

30 CFR 49.7

Burden Statement:

Public reporting burden for this collection of
information is estimated to average 15 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 the collection of information, including
suggestions for reducing this burden, to the Mine Safety and Health
Administration, U.S. Department of Labor, Office of Standards,
Regulations and Variances, 1100 Wilson Boulevard, Arlington,
Virginia 22209-3939.

Persons are not required to respond to
this collection of information unless it displays a currently valid
OMB control number.

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U.S. Department of Labor | Mine Safety and Health
Administration (MSHA) | 1100 Wilson Boulevard, 21st
Floor | Arlington, VA 22209-3939
http://www.msha.gov/ | Telephone:
(202) 693-9400 | Fax-on-demand: (202) 693-9401