Information Collection

49.17/ MSHA Form 5000-3

IC 208444 under ICR 201611-1219-002 · OMB 1219-0144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form MSHA Form 5000-3 49.17/ MSHA Form 5000-3	Form and Instruction
MSHA Form 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/elawsforms/5000-3.htm	Form and Instruction
MSHA FORM 5000-3 Certificate of Physical Qualification for Mine Rescue Wo MSHA Form 5000-3 Intro Screen.pdf www.msha.gov/forms/elawsforms/5000-3.htm	Form and Instruction

IC Title:

49.17/ MSHA Form 5000-3

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.17

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	MSHA Form 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/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA FORM 5000-3	Certificate of Physical Qualification for Mine Rescue Work (Intro Screen)	MSHA Form 5000-3 Intro Screen.pdf	http://www.msha.gov/forms/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 128

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	896	-336	1,232
Annual IC Time Burden (Hours)	224	-84	308
Annual IC Cost Burden (Dollars)	268,800	-39,200	308,000

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.