Information Collection

Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons

IC 14446 under ICR 202002-1219-006 · OMB 1219-0078.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5000-3 Certificate of Physical Qualification for Mine Rescue Work Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons	Form and Instruction
5000-3 Certificate of Physical Qualification for Mine Rescue Wo 5000-3 CERT of Physical Qualification for Mine Rescue Work (OMB).pdf www.msha.gov/support-resources/forms-online-filing/2015/04/15/certificate-physical-qualification-mine-rescue-work	Form and Instruction
Certificate of Physical Qualification for Mine Rescue Work.pdf Forms and Filings Intro Page for Form MSHA-5000-3	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.3 30 CFR 49.4 30 CFR 49.2 30 CFR 49.5 30 CFR 49.6 30 CFR 49.7 30 CFR 49.8 30 CFR 49.9

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	5000-3			https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/certificate-physical-qualification-mine-rescue-work	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 202

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
	Requested	Previously Approved
Annual Number of Responses for this IC	19,973	19,973
Annual IC Time Burden (Hours)	9,941	9,941
Annual IC Cost Burden (Dollars)	309,068	309,068

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Forms and Filings Intro Page for Form MSHA-5000-3		07/24/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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