Form MSHA Form 2000-224 MSHA Form 2000-224 Operator’s Annual Certification of Mine Rescue Team Qual

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

Operator’s Annual Certification of Mine Rescue Team Qualifications
This form is affected by the Privacy Act of 1974

Form Approved: OMB Number 1219-0144 Approval Expires October 31, 2013

Public reporting burden for this collection of information is estimated to average 31 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing the form. This collection of information is voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments
regarding the accuracy of the burden estimate and any suggestions for reudcing the burden to: to DOL/MSHA, Office of Standards Regulations and Variances, 1100 Wilson Blvd., Arlington, VA 22209, Paperwork Reduction
Project (1219-0144), NOTE: Do not send your completed form to this address.

MSHA Mine ID No.:

Contractor ID No.:

Company Name:
Mine size:

Team Name:

Type of Team:

О

О

Ο Large Ο Small

Mine Name:

О Mine-site Ο Composite Ο Contract Ο State-sponsored
О

Mine Rescue Team is available within 1-hour ground travel time from the Mine Rescue Station
Address of Mine Rescue Station:

Member’s name

1

2

Team is available at all times when
miners are underground

3

4

Appropriate mine rescue equipment
is provided, inspected, tested, &
maintained
$OWHUQDWH

5

Employer’s name
Experience working
in underground coal
mine

Ο

Ο

Ο

Ο

Ο

Ο

Physically fit

Ο

Ο

Ο

Ο

Ο

Ο

New member training Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Annual training

Ο Refresher training
totals 96 hr or more

Ο Refresher training
totals 96 hr or more

Ο Refresher training
totals 96 hr or more

Ο Refresher training
totals 96 hr or more

Ο Refresher training
totals 96 hr or more

Ο Refresher training
totals 96 hr or more

8 hr training every
2 mos; includes
wearing apparatus
for 2 hr

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

Ο Jan-Feb
Ο Mar-Apr
Ο May-Jun
Ο Jul-Aug
Ο Sep-Oct
Ο Nov-Dec

MSHA Form 2000-224, December 2012, Page 1 of 2

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

Operator’s Annual Certification of Mine Rescue Team Qualifications
Trains underground
every 6 mos

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Wears apparatus in
smoke annually

Ο

Ο

Ο

Ο

Ο

Ο

Familiar with
operations of mine

Ο

Ο

Ο

Ο

Ο

Ο

Knowledge of
operations &
ventilation of mine

Ο

Ο

Ο

Ο

Ο

Ο

Participates in two
local mine rescue
contests (Insert dates)

Trains at this mine
(Insert dates)

I certify the information above is true and accurate to the best of my knowledge.
Printed Name &
Signature:

Date:

Position held at the mine:

Use of this form is optional.
An underground coal mine operator may file a copy of this form with the appropriate District Manager for each of the two designated
mine rescue teams, that provide coverage for this mine, to certify that each team meets the requirements of 30 CFR Part 49 Subpart B.

MSHA Form 2000-224, December 2012, Page 2 of 2