Forms and Filings Gateway Page for Form MSHA-5000-3

MSHA - Forms and Online Filings - Form 5000-3 - Certificate of Physical Qualification for Mine Rescue Work

UNITED STATES
DEPARTMENT OF LABOR

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MSHA Form 5000-3

Form name:

Certificate of Physical Qualification for Mine Rescue Work

Description:

Title 30, CFR § 49 requires the mine operator of an underground
mine to establish at least two mine rescue teams to be available
at all times that miners are underground, or the operator must
enter into an arrangement for mine rescue services which
assures that at least two teams are available at all times when
miners are underground.

Under Title 30, CFR § 49.7, each mine rescue team member
must be examined by a physician annually, with the first
examination being completed within 60 days prior to scheduled
initial training. An MSHA Form 5000-3 for each team member
must be completed and signed by the examining physician.
These forms shall be kept on file at the mine rescue station for a
period of one year.

OMB Control Number
and
Expiration Date:

1219-0078 and 1219 0144; Approval Expires 12/31/2016

Filing Options:

Form 5000-3 should be printed and filled in manually. This form
must be completed and signed by the examining physician for
each member of a mine rescue team. These forms shall be kept
on file at the mine rescue station for a period of 1 year.
Get Form

Contact Information:

Questions regarding this form should be directed to MSHA at
(877) 778-6055 or [email protected]

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 49.7

Burden Statement:

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 needed, and completing and
reviewing the collection 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, 201 12th Street South, Arlington,
Virginia 22202-5452.

Persons are not required to respond to this collection of
information unless it displays a currently valid OMB control
number.

http://www.msha.gov/forms/elawsforms/5000-3.htm[12/14/2015 2:18:44 PM]

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U.S. Department of Labor | Mine Safety and Health Administration (MSHA) | 201 12th Street South,  | Arlington, VA 22202-5452
www.msha.gov | TTY | Telephone: (202) 693-9400 

http://www.msha.gov/forms/elawsforms/5000-3.htm[12/14/2015 2:18:44 PM]