Form 5000-23 Certificate of Training

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

Certificate of Training
MSHA Form 5000-23, Jan. 99 (revised)

Persons are not required to respond to the collection of
information unless it displays a currently valid OMB control
number.
Public reporting burden for this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining data needed, and completing and reviewing the collection of information. This is a
mandatory collection of information as required by 30 CFR Part 48.9 and 48.29. The information
provides MSHA with a monitoring tool for determining compliance requirements. The Certificate of
Training provides a means for operators to record and certify mandatory training received by miners.
Send comments regarding the collection of information, including suggestions for reducing this burden
to the U.S. Department of Labor, Mine Safety and Health Administration, Office of Standards,
Regulations and Variances, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939.

DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE

U.S. Department of Labor

Certificate of Training

Mine Safety and Health Administration

Approved OMB Number 1219-0009, Expires July 31, 2014.

This certificate is required under Public Law 91-173 as amended by Public Law
95-164. Failure to comply may result in penalties and other sanctions as provided
by sections 108 and 110, Public Law 91-173 as amended by Public Law 95-164.
Serial Number (for operator’s use)

Issue Certificate Immediately
Upon Completion of Training
1. Print Full Name of Person Trained (first, middle, last)

2. Check Type of Approved Training Received:
Annual
Experienced Miner
Refresher
Newly Employed
New Task
Inexperienced Miner
(specify below)

Hazard Training

¢

Date

Task

Date

Initials
Instr

Coal

Task

Initials
Instr

Studt

3. Check Type of Operation and Related Industry:
A.
Surface
Construction

B.

Other (specify)

Underground

Metal

Studt

Shaft & Slope

Nonmetal

4. Date Training Requirements Completed

Check if not completed
and go to item 5, below.

¦ If completed, go to item 6, below.

5. Check Subjects Completed (Use only for partially completed training):
Introduction to Work Environment
Hazard Recognition

Roof/Ground Control
& Ventilation

Health
ElectricalHazards

Emergency Medical Procedures

Mine Map; Escapeways;
Emergency Evacuation;
Barricading

First Aid

H&S Aspects of Tasks Assigned

Cleanup; Rock Dusting

Mine Gases

Statutory Rights of Miners

Mandatory Health &
Safety Standards

Explosives

Self-Rescue & Respiratory Devices

Authority & Responsibility
of Supervisors & Miners
Representatives

Transport & Communications Systems

6. False certification is punishable under
section 110 (a) and (f) of the Federal Mine
Safety & Health Act (P. L. 91-173 as
amended by P. L. 95-164).

Prevention of Accidents
Other (specify)

I certify that the above training has been completed
(signature of person responsible for training)

7. Mine Name, ID, & Location of Training (if institution, give name & address)

8. Date

I verify that I have completed the above training
(signature of person trained)

MSHA Form 5000-23, Jan. 99 (revised)

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