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Forms and Online Filings

Form number:

MSHA Form 5000-41

Form name:

Health Activity Certification or Hoisting Engineers Qualification Request Form

Description:

All instructors are required to submit to MSHA the names of persons who have satisfactorily completed required mine foreman and pre-shift examiner or hoisting certification training. The 5000-41 is a combined version of the previous 5000-4 and 5000-7 forms. MSHA uses the form information to issue certification cards to qualified persons.

OMB Control Number and Expiration Date:

1219-0127; 7/31/2011

Filing Options:

Form 5000-41, Health Activity Certification or Hoisting Engineers Qualification Request Form can be either filed online or printed, filled in and sent to MSHA according to the instructions below.

File online
Print, fill in and mail or fax

Filing Instructions:

Detailed instructions for filing Form 5000-41, Health Activity Certification or Hoisting Engineers Qualification Request Form are available in HTML or PDF.

If filing by mail or fax, completed printed forms should be sent to:

MSHA Qualification and Certification
P.O. Box 25367
Denver, Colorado 80225-0367
Fax: (303) 231-5474

Contact Information:

Questions regarding this form should be directed to MSHA at (877) 778-6055 or
zzMSHA-PEIRHelpDesk@dol.gov

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 75.100, 30 CFR 77.100 (Health and Safety Certification) establish the procedures under which miners are certified to make certain tests and examinations which are required by MSHA regulations to be performed by certified persons. For mines located in states that do not have provisions for certifying miners, 30 CFR 75.100 (c) (1) and 30 CFR 77.100 (b) (2) require mine operators to make application to MSHA to obtain certification for miners who meet certain minimum experience requirements. A certified person is one who has been certified as a Foreman, Assistant Foreman (UG only), or Pre-shift Examiner (UG only).

30 CFR 75.155 and 30 CFR 77.105 (Hoisting Engineers Qualification) establish the procedures under which miners are qualified to operate hoists (Steam Driven/Electrical-UG; Slope & Shaft Sinking Operation-Sur). For mines located in states that do not have provisions for qualifying hoist operators, 30 CFR 75.155/77.105 requires mine operators to apply to MSHA to obtain qualification for miners who meet certain minimum experience requirements.

Burden Statement:

Public reporting burden for this collection of information is estimated to average 10 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 information. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Information Management, Department of Labor, Room N-1301, 200 Constitution Avenue, N.W., Washington, D.C. 20210; and to the Office of Management and Budget, Paperwork Reduction Project (1219-0069), Washington, D.C. 20503. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

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