Agency:

MSHA

Title:

Health Activity Certification or Hoisting Engineers Qualification Request Form

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:

1219-0127

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