5000-23 Certificate of Training

U.S. Department of Labor

Mine Safety and Health Administration

Certificate of Training
MSHA Form 5000-23, May 2013 (revised)

Persons are not required to respond to the collection of
information unless it displays a currently valid OMB control
number.
Public reporting burden for this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining data needed, and completing and reviewing the collection of information. This is a
mandatory collection of information as required by 30 CFR Part 48.9 and 48.29. The information
provides MSHA with a monitoring tool for determining compliance requirements. The Certificate of
Training provides a means for operators to record and certify mandatory training received by miners.
Send comments regarding the collection of information, including suggestions for reducing this burden
to the U.S. Department of Labor, Mine Safety and Health Administration, Office of Standards,
Regulations and Variances, 201 12th Street South, Suite 401, Arlington, Virginia 22202-5452.

DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE

U.S. Department of Labor

Certificate of Training

Mine Safety and Health Administration

Approved OMB Number 1219-0009, Expires April 30, 2021.

This certificate is required under Public Law 91-173 as amended by Public Law
95-164. Failure to comply may result in penalties and other sanctions as provided
by sections 108 and 110, Public Law 91-173 as amended by Public Law 95-164.



Serial Number (for operator’s use)

Issue Certificate Immediately
Upon Completion of Training

1. Print Full Name of Person Trained (first, middle, last)
2. Check Type of Approved Training Received:
Annual
Experienced Miner
Refresher
New Task
(specify below)
Date

Task

Hazard Training
Other (specify)

New Miner
Initials
Instr

Date

Task

Instr

Studt

Check Type of Operation and Related Industry:
A.
Surface
Construction

Underground

B.

Nonmetal

Coal

Metal

Initials

4. Date Training Requirements Completed

Studt

Shaft & Slope

Check if not completed
and go to item 5, below.

If completed, go to item 6, below.
5. Check Subjects Completed (Use only for partially completed training):
Introduction to Work Environment
Hazard Recognition

Roof/Ground Control
& Ventilation

Emergency Medical Procedures

Mine Map; Escapeways;
Emergency Evacuation;
Barricading

H&S Aspects of Tasks Assigned

Cleanup; Rock Dusting

Statutory Rights of Miners

Mandatory Health &
Safety Standards

Self-Rescue & Respiratory Devices
Transport & Communications Systems

6. False certification is punishable under
section 110 (a) and (f) of the Federal Mine
Safety & Health Act (P. L. 91-173 as
amended by P. L. 95-164).

Authority & Responsibility
of Supervisors & Miners
Representatives

Health
Electrical Hazards
First Aid
Mine Gases
Explosives
Prevention of Accidents
Other (specify)

I certify that the above training has been completed

(signature of person responsible for training)

7. Mine Name, ID, & Location of Training (if institution, give name & address)

8. Date

I verify that I have completed the above training
(signature of person trained)

MSHA Form 5000-23, May, 2013 (revised)

Print
Print Form

Instructions for Completing a Mine Safety and Health
Administration Certificate of Training Form (5000-23)
All part 48 training must be properly recorded on a Mine Safety and Health Administration (MSHA)
Form 5000-23 (training certificate), or on an MSHA approved alternate form. For additional policy
information on the 5000-23 form, you may refer to the MSHA Program Policy Manual. To review the
applicable policy please use this link.
The current MSHA Form 5000-23 has an expiration date of April 30, 2021, however, previously issued
forms with an earlier expiration date may still be used. The printed version comes with four copies.
Listed below are notations, which appear on the bottom right-hand side of the form, showing the
intended use of each copy:
Copy 1 (white) - Employer's Personnel Record Copy 2 (pink)
- Employee's Record Copy Copy 3 (yellow)
- Employee's Separation Copy Copy 4 (green)
- Record Keeping
The following is a description of how to complete each item of the 5000-23.

ITEM

Serial Number

(for operator's use)

Item 1. Print Full Name of Person
Trained
(first, middle, last)

Item 2. Check Type of
Approved Training Received

DESCRIPTION.

This is an optional field which may
be used to help track employees by
an identification number. There is
no Federal requirement to use this
field.
Enter the person's name who has
received the training.
There are five boxes for the five types
of training required. Check the
appropriate box(es) to indicate what
training was given.
When New Task is checked, additional
space is provided to record 1-8 task
training events. This space is used to
identify each task and to allow for the
initials of the instructor(s) and the
student (miner), as needed.

Item 3. Check Type of Operation
and Related Industry

Item 4. Date Training
Requirements Completed

(1) Mark the box for the appropriate
commodity: coal, metal or nonmetal.
(2) Mark the box for the appropriate
location: surface or underground. (3)
Mark the appropriate box if the
training is for construction or shaft
and slope work. When completed the
box should identify the type of
mining, location and if construction or
shaft and slope activities are
involved.
Depending on whether the training is
complete or partial will determine how
this item is completed. Only entering
a date indicates that the training
marked in item 2 is completed.
Placing a check in the box to the right
of the date entry, indicates that the
training for the program(s) marked in
item 2
is not complete. The appropriate
boxes in item 5 must then be checked
to indicate what subjects were
completed.

The following are some examples of
partially completed training: (1)
training for new miners given away
from the mine site (which will then
require site specific training at the
mine site); (2) utilizing the 8 and 16
hours of new miner training within 60day provision for new surface miners;
and (3) providing partially completed
annual refresher training.
Item 5. Check Subjects Completed This is generally used for conducting
(use only for partially completed training) annual refresher training in
increments throughout an annual
refresher cycle; or for new miner
training which does not cover mine
specific courses that are required to
be covered at the mine site.
Upon completion of an MSHA
Item 6. Signature of
approved training program, such as
person responsible for
experienced miner, task, or annual
training
refresher training, you must record
and certify on the 5000- 23 form that
the miner has received the specified
training.

The person signing the form in item 6
is representing that the miner has
received the indicated training.
Anyone falsifying the 5000-23 form is
criminally liable under section 110(a)
and (f) of the Federal Mine Safety
and Health Act.
Generally, the person signing the
form is the mine operator or a person
acting on behalf of the operator. For
example, a company safety official, a
trainer employed or contracted by the
operator, or a cooperative instructor
(such as, a state grantee).
Item 7. Mine Name, ID, & Location List the mine name, mine ID and
location where training was
of Training
(if institution, give name & address)
conducted. If the training was
conducted by a cooperative instructor
or state grantee and a class
participant is not employed at a
particular mine, fill in the cooperative
instructor's name or state name and
address.
The person trained has the option of
Item 8. Date and (signature of
signing and dating the form,
person trained)
acknowledging that the training
indicated on the form was received.
A copy of the 5000-23 form must be
given to the miner upon completion
of each MSHA approved training
program, such as experienced miner,
task, or annual refresher training.