Form 5000-1 Certificate of Electrical Training

Certificate of Electrical Training
This form is affected by the Privacy Act of 1974

Reset Form

MSHA Form 5000-1

U.S. Department of Labor
Mine Safety and Health Administration

Approved for use through May 31, 20XX, OMB Number 1219-0001. This form replaces previous versions of Form 5000-1

Item 1. Company Name and Address (If the address below is blank,
information will be sent to address selected in Item 8.)

Item 7. Date Completed

Item 2. Mine ID and/or Contractor ID

D D

M M

Company Name

Y

Y

Y

Y

Item 3. Instructor’s Name

Attn:
Street 1

Item 4. Instructor’s Social Security Number:
Street 2
Item 5. Name of County and State Where Training Took Place

(State 2 Letter Alpha)

City
State

Item 6. AR/ROE No. (MSHA only)

Zip

Item 12.
MSHA
Use Only

Surface Reinstatement (RS)

1.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Underground Reinstatement (RU)

Last

Item 10. Address If Sent To The Miner

Surface Retraining (EE)

Item 9. Name (Last, First, MI)

Underground Retraining (EC)

Item 8. Social Security Number

Surface Initial (ED)

30 CFR 75.153 and 77.103 (Electrical work Qualified person) establish the procedures under which miners are qualified to perform electrical work in the underground and surface coal mines.
MSHA Form 5000-1 provides coal mine operators with a standard reporting format which expedites the certification and qualification process while ensuring compliance with regulations. The information provided
on the form enables MSHA to determine if miners satisfy the requirements to obtain the certification/qualification sought. This collection of information is covered by the Privacy Act notice published in the Federal
Register. Computer safeguards are as described in the National Bureau of Standards Publication, Computer Security Guidelines for Implementing the Privacy Act of 1974, and in accordance with procedures developed by MSHA under GSA Circular E-34.
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
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:
Records Management Branch
Mine Safety and Health Administration
1100 Wilson Boulevard
Arlington, VA 22209-3939

Underground Initial (EB)

Item 11.
Electrical Codes

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:

Last

2.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:

Last

3.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:
Zip:

State:

4.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Surface Reinstatement (RS)

Last

Underground Reinstatement (RU)

MSHA Qualification & Certification
P.O. Box 25367
Denver, CO. 80225
Phone (303) 231-5472
Fax (303) 231-5474

Surface Retraining (EE)

Return to:

Underground Retraining (EC)

Continued from page 1

Surface Initial (ED)

U.S. Department of Labor
Mine Safety and Health Administration
Underground Initial (EB)

Certificate of Electrical Training

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:

Last

5.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:

Last

6.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:
Last

7.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:

Last

8.

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Address (Item 10)

Attn:
Street 1:

First
MI

Street 2:
City:

State:

Zip:
False certification is punishable under section 110(a) and (f) of the Federal
Mine Saftely and Health Act (PL 91-173 as amended by PL 95-164).

Item 13. Signature for Instructor (I certify that the above individuals have completed the course/s indicated.)

Instructions for Completing MSHA Form 5000-1
· Item 1. Company Name and Address
If in Item 8 on the form, Company Address is checked the full name and address of the company is required in. This will
be the address used to mail the Electrical Qualification cards.
· Item 2. Mine ID or Contractor ID
The MSHA assigned MID or CID number may be filled in. This number was assigned by MSHA. If in Item 8 Mine
Address or Contractor Address is marked then this becomes a required field. MSHA is no longer using miscellaneous
Mine ID’s or Contractor ID’s example: XX-77003 and XX-77004.
· Item 3. Instructor’s Name (Required)
Provide the Last Name, First Name of the instructor who gave the electrical training.
· Item 4. Instructor’s Social Security Number (Required)
This is a required field. The instructor is only allowed to teach what they are approved to teach through MSHA.
· Item 5. Name of the County and State Where Training Took Place (Required)
This is a required field. County and State is required to provide information to the appropriate district if the MID or CID is
not used.
· Item 6. AR/ROE No. (Required if training provided MSHA or MSHA is reinstating the qualification)
This field is for MSHA use only.
· Item 7. Date Training Completed (Required)
This is a required field for the date that the training was completed.
· Item 8. Social Security Number and Choice for Where to Mail Cards (Required)
This is a required field. The individuals' social security number is required. The box as to where to mail qualification cards
is also required. If the box labeled Mine Address or Contractor Address is checked then Item 2 becomes a required field. If
box Company Address is checked then Item 1 is required. If the box Miner Address is checked then Item10 becomes a
required field.
· Item 9. Name (Required)
This is a required field. Input the Last, First, Middle Initial for the individual that has receiving the training.
· Item 10. Address if Sent to the Miner
Fill in the Miners information if in Item 8 the box Miner Address was selected. This is the address that the cards will be
mailed to.
· Item 11. Electrical Codes (Some or all codes required)
These check boxes should be used to indicate which training the individual received.
EB- Initial Underground Training
ED- Initial Surface Training
EC- Retraining Underground
EE- Retraining Surface
· Item 12. MSHA Use only [codes]
Only MSHA personnel may use these codes. RU, RS codes are now used to reinstate Electrical Qualification.
RU- Reinstatement Underground
RS- Reinstatement Surface
· Item 13. Signature of Instructor (Required)
The signature of the Instructor mention in Item 3 must appear here to "Certify that the above individuals have completed
the course(s) indicated."
Return to:
MSHA Qualification & Certification
P.O. Box 25367
Denver, CO. 80225
Phone (303) 231-5472
Fax (303) 231-5474
Privacy Act Statement
30 CFR 75.153, and 77.103 authorize the collection of this information. This information will be used to determine if
miners satisfy the requirements to obtain the certification/qualification sought and for MSHA to maintain a record of these
qualifications. Submission of the items identified in the instructions as required is mandatory and failure to submit the
required information may delay or prevent action on the application. Collection of social security numbers as part of this
form is mandatory and is authorized by Sec. 7(a)(2)(B) of the Privacy Act.