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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0127 can be found here:

Documents and Forms

Document Name Document Type
Form MSHA Form 5000-41 Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties Form
Intro 5000-41.pdf www.msha.gov/support-resources/forms-online-filing/2015/04/15/health-activity-certification-or-hoisting-engineers Instruction
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41 2017.pdf www.msha.gov/sites/default/files/Support_Resources/Forms/5000-41.pdf Form
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41_screenshots.docx www.msha.gov/sites/default/files/Support_Resources/Forms/5000-41.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 77.106 30 CFR 77.100 30 CFR 77.105 30 CFR 77.107 30 CFR 77.107-1 30 CFR 75.100 30 CFR 75.155 30 CFR 75.160 30 CFR 75.159 30 CFR 77.161

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41 2017.pdf	https://www.msha.gov/sites/default/files/Support_Resources/Forms/5000-41.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41_screenshots.docx	https://www.msha.gov/sites/default/files/Support_Resources/Forms/5000-41.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			Intro 5000-41.pdf	https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/health-activity-certification-or-hoisting-engineers	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: DOL/MSHA-1, Mine Safety and Health Administration Standardized Information System (MSIS)	FR Citation: 81 FR 25766

Number of Respondents: 957	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,590	-1,069	5,659
Annual IC Time Burden (Hours)	465	-83	548
Annual IC Cost Burden (Dollars)	77	6	71

Documents for IC

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.