Information Collection

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

IC 14446 under ICR 201208-1219-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 MSHA-5000-3(2013).pdf www.msha.gov/forms/5000-3.pdf	Form and Instruction
MSHA - Forms and Online Filings - Form 5000-3 - Certificate of Physical Qualification for Mine Rescue Work.mht Forms and Filings Gateway Page for Form MSHA-5000-3	IC Document
MSHA - Form 5000-3 (Certification of Physical Qualification for Mine Rescue Work ) Disclaimer.mht Disclaimer	IC Document

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 49.3 30 CFR 49.2 30 CFR 49.4 30 CFR 49.9 30 CFR 49.6 30 CFR 49.8 30 CFR 49.7

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	MSHA-5000-3(2013).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: 254

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	20,043	3,170	16,873
Annual IC Time Burden (Hours)	10,111	1,286	8,825
Annual IC Cost Burden (Dollars)	309,067	66,018	243,049

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Forms and Filings Gateway Page for Form MSHA-5000-3	MSHA - Forms and Online Filings - Form 5000-3 - Certificate of Physical Qualification for Mine Rescue Work.mht	02/06/2013
Disclaimer	MSHA - Form 5000-3 (Certification of Physical Qualification for Mine Rescue Work ) Disclaimer.mht	02/06/2013

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