Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties

Health Activity Certification or Hoisting Engineers Qualification Request | Mine Safety and Health Administration (MSHA)

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HOISTING ENGINEERS QUALIFICATION REQUEST

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HEALTH ACTIVITY CERTIFICATION OR

Health Activity Certification or
Hoisting Engineers Qualification
Request

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Form ID: 5000-41

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Description: 

Print

All instructors are required to submit to MSHA the names of persons who have
External Mining
Resources

satisfactorily completed required mine foreman and pre-shift examiner or
hoisting certification training. The 5000-41 is a combined version of the
previous 5000-4 and 5000-7 forms. MSHA uses the form information to issue
certification cards to qualified persons.
Control ID: 1219-0127
Expiration Date: December 31, 2017
Filing Options: 
Form 5000-41, Health Activity Certification or Hoisting Engineers Qualification
Request Form can be either filed online or printed, filled in and sent to MSHA
according to the instructions below.
File online

https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/health-activity-certification-or-hoisting-engineers[9/27/2017 11:23:34 AM]

Health Activity Certification or Hoisting Engineers Qualification Request | Mine Safety and Health Administration (MSHA)

Fill in, print and mail or fax
Change online filing registration information
Filing Instructions: 
Detailed instructions for filing Form 5000-41, Health Activity Certification or
Hoisting Engineers Qualification Request Form are available in HTML or PDF.
If filing by mail or fax, completed printed forms should be sent to:
MSHA Qualification and Certification
P.O. Box 25367
Denver, Colorado 80225-0367
Fax: (303) 231-5474
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 75.100, 30 CFR 77.100 (Health and Safety Certification) establish the
procedures under which miners are certified to make certain tests and
examinations which are required by MSHA regulations to be performed by
certified persons. For mines located in states that do not have provisions for
certifying miners,30 CFR 75.100 (c) (1) and 30 CFR 77.100 (b) (2) require mine
operators to make application to MSHA to obtain certification for miners who
meet certain minimum experience requirements. A certified person is one who
has been certified as a Foreman, Assistant Foreman (UG only), or Pre-shift
Examiner (UG only). 
30 CFR 75.155 and 30 CFR 77.105 (Hoisting Engineers Qualification) establish
the procedures under which miners are qualified to operate hoists (Steam
Driven/Electrical-UG; Slope & Shaft Sinking Operation-Sur). For mines located
in states that do not have provisions for qualifying hoist operators, 30 CFR
75.155/77.105 requires mine operators to apply to MSHA to obtain qualification
for miners who meet certain minimum experience requirements.
Burden Statement: 
Public reporting burden for this form is estimated to average 10 minutes per
response for the electronic version and 17 minutes per response for the hard

https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/health-activity-certification-or-hoisting-engineers[9/27/2017 11:23:34 AM]

Health Activity Certification or Hoisting Engineers Qualification Request | Mine Safety and Health Administration (MSHA)

copy. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed,
and completing and submitting the form. This collection of information is
mandatory. You are not required to respond to this collection of information
unless it displays a valid OMB control number. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden
to: to DOL/MSHA, Office of Standards Regulations and Variances, 201 12th
Street South, Suite 401 Arlington, VA 22202-5450, Paperwork Reduction
Project (1219-0127). 
NOTE: Do not send your completed form to this address.
Online Filing: 
File Online

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https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/health-activity-certification-or-hoisting-engineers[9/27/2017 11:23:34 AM]