Information Collection

Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons

IC 14446 under ICR 201508-1219-004 · OMB 1219-0078.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0078 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5000-3 Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons	Form and Instruction
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/5000-3.pdf	Form and Instruction
MSHA - Forms and Online Filings - Form 5000-3 - Certificate of Physical Qualification for Mine Rescue Work.pdf Forms and Filings Gateway Page for Form MSHA-5000-3	IC Document
MSHA - Form 5000-3 (Certification of Physical Qualification for Mine Rescue Work ) Disclaimer.pdf Disclaimer	IC Document

IC Title:

Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.5 30 CFR 49.5 30 CFR 49.6 30 CFR 49.3 30 CFR 49.7 30 CFR 49.8 30 CFR 49.9

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 and Instruction	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/5000-3.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 215

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,041	-2	20,043
Annual IC Time Burden (Hours)	10,109	-2	10,111
Annual IC Cost Burden (Dollars)	309,067	0	309,067

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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.pdf	12/14/2015
Disclaimer	MSHA - Form 5000-3 (Certification of Physical Qualification for Mine Rescue Work ) Disclaimer.pdf	12/14/2015

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