Certificate of Physical Qualification for Mine Rescue Work _ Mine Safety and Health Administration (MSHA) more information

3/14/23, 9:24 AM

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

U.S. DEPARTMENT OF LABOR

Mine Safety and Health Administration

Certificate of Physical
Qualification for Mine Rescue
Work
Form ID: 5000-3
Description
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: Mon, 07/31/2023 - 13:30
Filing Options
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.
Get Form
Contact Information

Questions regarding this form should be directed to MSHA at (877) 778-6055
or [email protected]

https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/certificate-physical-qualification-mine-rescue

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

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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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U.S. DEPARTMENT OF LABOR
Mine Safety and Health Administration
201 12th St S
Suite 401
Arlington, VA 22202-5450
www.msha.gov
TTY 202-693-9400

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

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