Information Collection

Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties

IC 14507 under ICR 201406-1219-006 · OMB 1219-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0127 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MSHA Form 5000-41 Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties	Form
Form 5000-41 Intro Screen.pdf www.msha.gov/forms/elawsforms/5000-41.htm	Instruction
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41.pdf www.msha.gov/forms/elawsforms/5000-41.htm	Form
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41_screenshots.docx www.msha.gov/forms/elawsforms/5000-41.htm	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 75.159 30 CFR 75.160 30 CFR 77.106 30 CFR 75.100 30 CFR 75.161 30 CFR 77.100 30 CFR 77.105 30 CFR 75.155 30 CFR 77.107 30 CFR 77.107-1

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	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41.pdf	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41_screenshots.docx	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable Signable
Instruction			Form 5000-41 Intro Screen.pdf	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: DOL/MSHA-15 Health & Safety Training and Examination Records

FR Citation: 67 FR 16815

Number of Respondents: 1,232

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,659	-1,307	6,966
Annual IC Time Burden (Hours)	548	-131	679
Annual IC Cost Burden (Dollars)	71	-54	125

Documents for IC

table that charts IC Documents
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.