Form MSHA Form 2000-222 MSHA Form 2000-222 SCSR Inventory & Report

SCSR Inventory and Report

U.S. Department of Labor

Mine Safety and Health Administration

OMB Control No. 1219-0141 (Expires 8/31/2016)

INSTRUCTIONS: This form is for Operators’ use in providing MSHA with complete SCSR inventories as well as in reporting
problems with SCSRs. Operators may attach continuation sheets to this form provided all required SCSR information is included. Enter
date information is being reported, MSHA- issued mine ID, name mine is operating under, company name, address of mine, contact
name and telephone number. Select the manufacturer/model, enter date of manufacture, serial number and report date. If “Other MSHAapproved SCSR ____” is selected, write in the manufacturer/model. The use of this form is voluntary in complying with 75.1714-8.
A false statement or representation is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act, as
amended (30 U.S.C. § 820(a) and (f)).

Report Date:____________________

E-mail:____________________

Mine ID: __________________
(MSHA Mine ID)

Mine Name: ______________________________________

Company Name:__________________________

Address: __________________________________________
(Street, P.O.)
_________________________________________________
City
State
Zip

Contact name: __________________________

Telephone:____________

Check all that apply

Manufacturer/Model
 CSE SR-100
 OCENCO EBA 6.5
 OCENCO M20
 DRAEGER OXY-K Plus
 DRAEGER OXY-K Plus S
 MSA LIFE-SAVER 60
 Other MSHA-approved SCSR_______

Create list below or attach to this form
Date of Manufacture
Serial Number

_________________
_________________
_________________
________________
_________________
_________________
_________________

____________
____________
____________
____________
____________
____________
____________

In/Out









Reason

________
________
________
________
________
________
________

If reporting an SCSR out of inventory, identify the SCSR and enter reason number above:
1) Out for Refurbishment
5) Transferred
Send this form to:

2) Damaged/Not Repairable
6) Used/Activated

3) Out of Date
7) Data Entry Error

4) Missing

Mine Safety and Health Administration
Technical Support
Pittsburgh Safety and Health Technology Center
Attn: SCSR Coordinator
Cochrans Mill Road
P.O. Box 18233
Pittsburgh, Pennsylvania 15236

Purpose: 30 CFR 75.1714-8 authorizes the collection of this information. MSHA maintains an inventory of all reported SCSR information to assure the
effectiveness of evacuation plans and emergency evacuations. In addition, such an inventory will assist in targeting SCSR recalls to specific mines. The
use of this form will facilitate SCSR inventory information transfer from mine operators to MSHA. MSHA may not sponsor or endorse products.
Burden Statement: Public reporting burden for this collection of information is estimated from 2 hours to 6 hours depending on the size of the mine per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection information. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control
Number. The DOL offers no pledge of confidentiality in association with these information collections. As a practical matter, the DOL would only release
this information in accordance with the provisions of the Freedom of Information Act (5 U.S.C. § 552); the Privacy Act (5 U.S.C. § 552a); and attendant
regulations, 29 C.F.R. parts 70 and 71. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: Office Standards, Regulations and Variances, Mine Safety and Health Administration, 201 12th Street South,
Suite 401, Arlington, VA 22202-5452. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.
MSHA Form 2000-222 (Rev. Aug. 2015) (Previous versions are usable.)