Form 5000-23 Certificate of Training

Mine Safety & Health Administration

Certificate of Training

OMB Control Number 1219-0009, Approval Expires 5/31/2027

This certificate is required under the Federal Mine Safety and Health Act of 1977 (Mine Act), Pub. L. 95-164 (Nov. 9, 1977), as amended.
Failure to comply may result in penalties and other sanctions as provided by sections 108 and 110 of the Mine Act.
This form is affected by the Paperwork Reduction Act (see page 4).
Issue Certificate immediately
upon Completion of Training

Serial Number (for operator's use)

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

2. Check Type of Approved Training Received:

Date

Annual Refresher

Experienced Miner

Hazard Training

New Task
(Specify below)

New Miner

Other (Specify)

Task

Initials
Instr

Date

Task

Initials
Instr

Studt

Studt

3. Check Type of Operation and Related Industry:
A.

Surface

Construction

Underground

B.

Coal

Metal

Nonmetal

Shaft & Slope

4. Date Training Requirements Completed
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
Emergency Medical Procedures
H&S Aspects of Tasks Assigned
Statutory Rights of Miners
Self-Rescue & Respiratory Devices
Transport & Communications Systems

Roof/Ground Control
& Ventilation

Health

Mine Map; Escapeways;
Emergency Evacuation;
Barricading

First Aid

Cleanup; Rock Dusting
Mandatory Health &
Safety Standards
Authority & Responsibility
of Supervisors & Miners
Representatives

Electrical Hazards

Mine Gases
Explosives
Prevention of Accidents
Other (specify)

I certify that the above training has been completed
6. False certification is punishable under section 110(a)
and (f) of the Mine Act.

(signature of person responsible for training)

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

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

8. Date

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MSHA Form 5000-23
(Rev.) February 2025
Previous editions are obsolete

Instructions for Completing 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 use this link.
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

DESCRIPTION

Serial Number

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.

(for operator's use)

Item 1. Print Full Name of Person
Trained

Enter the person's name who has received the training.

(first, middle, last)

Item 2. Check Type of
Approved Training Received

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.

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MSHA Form 5000-23
(Rev.) February 2025
Previous editions are obsolete

Instructions for Completing Mine Safety and Health Administration
Certificate of Training, Form 5000-23
Item 3. Check Type of Operation
and Related Industry

(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.

Item 4. Date Training
Requirements Completed

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 60-day provision for new surface
miners; and (3) providing partially completed annual
refresher training.

Item 5. Check Subjects Completed

This is generally used for conducting 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.

(use only for partially completed training)

Item 6. Signature of
person responsible for
training

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Upon completion of a MSHA approved training
program, such as experienced miner, task, or annual
refresher training, you must record and certify on the
5000-23 form that the miner has received the specified
training.

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MSHA Form 5000-23
(Rev.) February 2025
Previous editions are obsolete

Instructions for Completing Mine Safety and Health Administration
Certificate of Training, Form 5000-23
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
of Training

List the mine name, mine ID and location where
training was 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.

(if instruction, give name & address)

Item 8. Date and (signature of
person trained)

The person trained has the option of signing and dating
the form, 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.

Persons are not required to respond to the collection of information unless it
displays a currently valid OMB control number.
The information for this form is required by section 115 of the Mine Act, 30 U.S.C § 825. According to the
Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
such collection displays a valid OMB control number. Public reporting burden for this collection of
information is estimated to average 5 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. The obligation to respond to this collection is mandatory. Send
comments regarding the burden estimate or any other aspect of this 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, 200 Constitution Avenue NW, Room
C3522 Washington, DC 20210. Note: Please do not return the completed form to this address.

DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE

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MSHA Form 5000-23
(Rev.) February 2025
Previous editions are obsolete