Forms and Filings Intro Page for Form MSHA-5000-3

Certificate of Physical Qualification for Mine Rescue Work | Mine Safety and Health Administration (MSHA)

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CERTIFICATE OF PHYSICAL QUALIFICATION

Certificate of Physical Qualification
for Mine Rescue Work

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Form ID: 5000-3
Description: 

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State Mining Agencies

Title 30, CFR § 49 requires the mine operator of an underground mine to
establish at least two mine rescue teams to be available at all times that miners
are underground, or the operator must enter into an arrangement for mine
rescue services which assures that at least two teams are available at all times
when miners are underground. 
Under Title 30, CFR § 49.7, each mine rescue team member must be
examined by a physician annually, with the first examination being completed
within 60 days prior to scheduled initial training. An MSHA Form 5000-3 for
each team member must be completed and signed by the examining physician.
These forms shall be kept on file at the mine rescue station for a period of one
year.
Control ID: 1219-0078 and 1219 0144
Expiration Date: May 29, 2020
Filing Options: 

https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/certificate-physical-qualification-mine-rescue-work[7/1/2019 11:50:39 AM]

Certificate of Physical Qualification for Mine Rescue Work | Mine Safety and Health Administration (MSHA)

Form 5000-3 should be printed and filled in manually. This form must be
completed and signed by the examining physician for each member of a mine
rescue team. These forms shall be kept on file at the mine rescue station for a
period of 1 year.
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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 49.7
Burden Statement: 
Public reporting burden for this collection of information is estimated to average
15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send comments
regarding the collection of information, including suggestions for reducing this
burden, to the Mine Safety and Health Administration, U.S. Department of
Labor, Office of Standards, Regulations and Variances, 201 12th Street South,
Suite 401 Arlington, VA 22202-5450. 
Persons are not required to respond to this collection of information unless it
displays a currently valid OMB control number.

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Certificate of Physical Qualification for Mine Rescue Work | Mine Safety and Health Administration (MSHA)
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