Form MSHA Form 5000-3 MSHA Form 5000-3 Certificate of Physical Qualification for Mine Rescue Wo

Certificate of Physical Qualification
for Mine Rescue Work

U.S. Department of Labor
Mine Safety and Health Administration
OMB Number 1219-0078 and 1219-0144, Approval expires 03/31/2016

30 CFR §§ 49.7 and 49.17 implements the provisions of Section 115(e) of the Federal Mine Safety and Health Act of 1977. Every operator
shall assure the availability of mine rescue capability for purposes of emergency rescue and recovery . In accordance with 30 CFR §§ 49.7 and
49.17, each member of a mine rescue team shall be examined annually by a physician who shall certify that he or she is physically fit to perform mine rescue and recovery work. The mine operator is required to keep the completed MSHA Form 5000-3 on file for a period of one year.
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 need, and completing and reviewing the collecion 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 control number.

Special Requirements:
1. Authority:

30 CFR §§ 49.7 and 49.17 Physical Reqs. for Mine Rescue Team Members and Alternates, and Exec. Order 12044

2. Principal Purpose:

To provide a routine check of miner ’s physical condition to wear oxygen breathing apparatus in mine rescue work

3. Routine Uses:

Certification is made by a physician and kept for one year at the mine rescue station. Completion of form requires
that examining physician list name and address of miner and employer and certify that the proper examination
has been made. Physical findings need not be listed on this form.

4. Disclosure is Mandatory: Without such information, miner cannot be considered for mine rescue work.
1. Individual’s name

2. Address (City, State and Zip Code)

3. Employer’s name

4. Address (City, State and Zip Code)

5. Note: 30 CFR §§ 49.7(b) and 49.17(b) states that the physician shall take the following conditions into consideration:
(a)
(b)
(c)
(d)
(e)
( f)
(g)
(h)
( i)

Seizure disorder;
Perforated eardrum;
Hearing loss without a hearing aid greater than 40 decibels at 400, 1,000 and 2,000 Hz;
Repeated blood pressure (controlled or uncontrolled by medication) reading which exceeds 160 systolic,
or 100 diastolic, or which is less than 105 systolic, or 60 diastolic;
Distant visual acuity (without glasses) less than 20/50 Snellen scale in one eye, and 20/70 in the other;
Heart disease;
Hernia;
Absence of a limb or hand; or
Any other condition which the examining physician determines is relevant to the question of whether the miner
is fit for rescue team service.
I certify that I have examined the individual listed above, and determined that he/she is physically fit
to perform mine rescue and recovery work for prolonged periods under strenuous conditions.

6. Physician’s signature
8. Physician’s address (City, State and Zip Code)
MSHA Form 5000-3 (rev.) Apr. 2013

7. Date