49.17/ MSHA Form 5000-3

Coal Mine Rescue Teams: Arrangements for Emergency Medical Assistance and Transportation for Injured Persons-Agreements, Reporting Requirements, and Posting Requirements

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0144 can be found here:

Documents and Forms

Document Name Document Type
Form MSHA Form 5000-3 49.17/ MSHA Form 5000-3 Form and Instruction
MSHA Form 5000-3 Certificate of Physical Qualification for Mine Rescue Wo 5000-3 CERT of Physical Qualification for Mine Rescue Work (FILLABLE).pdf www.msha.gov/forms/elawsforms/5000-3.htm Form and Instruction
MSHA FORM 5000-3 Certificate of Physical Qualification for Mine Rescue Wo MSHA Form 5000-3 Intro Screen.pdf www.msha.gov/forms/elawsforms/5000-3.htm Form and Instruction

Information Collection (IC) Details

IC Title:	49.17/ MSHA Form 5000-3	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.17

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	MSHA Form 5000-3	Certificate of Physical Qualification for Mine Rescue Work	5000-3 CERT of Physical Qualification for Mine Rescue Work (FILLABLE).pdf	http://www.msha.gov/forms/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA FORM 5000-3	Certificate of Physical Qualification for Mine Rescue Work (Intro Screen)	MSHA Form 5000-3 Intro Screen.pdf	http://www.msha.gov/forms/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 176	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,232	1,232
Annual IC Time Burden (Hours)	308	308
Annual IC Cost Burden (Dollars)	308,000	308,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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