Form MSHA Form 5000-1 MSHA Form 5000-1 Certificate of Electrical Training

Reset Form
Certificate of Electrical Training

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

This form is affected by the Privacy Act of 1974

Form Approved: OMB Number 1219-001. Approval Expires June 30, 2010

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

Item 2. Mine ID or Contractor ID

Item 7. Date Completed (MM/DD/YYYY)

Company Name

Item 3. Instructor Name

Attn:

Item 4. Instructor’s MSHA Individual Identification Number (MIIN)

Street 1

Item 5. County and State Where Training Took Place

(State 2 Letter Alpha)

Street 2
City

State

Zip

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

Item 12.
MSHA
Use Only
Surface Reinstatement (RS)

Last Name

Underground Reinstatement
(RU)

MIIN

Item 10. Miner Requested Send To Address

Surface Retraining (EE)

Item 9. Name (Last, First, M)

Underground Retraining (EC)

Item 8. MSHA Individual Identification Number
(MIIN) and address selector

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 25 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:

Mine Address (MSHA File)

1

Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

Last Name
Street 1:
Mine Address (MSHA File)

2

Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

3

Last Name
Street 1:

Mine Address (MSHA File)
Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:
MI

MSHA Form 5000-1, January 2008 (Revised -- Previous Editions are Obsolete)

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State:

Zip:

Surface Retraining (EE)

Underground Reinstatement
(RU)

Surface Reinstatement (RS)

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

Underground Retraining (EC)

Return to:

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:
MIIN

Last Name
Street 1:

Mine Address (MSHA File)

4

Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

Last Name
Street 1:

Mine Address (MSHA File)

5

Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

Last Name
Street 1:

Mine Address (MSHA File)

6

Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

Last Name
Street 1:

Mine Address (MSHA File)

7

Contractor Address (MSHA File)

Street 2:

First Name

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI
Attn:

MIIN

8

Last Name
Street 1:

Mine Address (MSHA File)
Contractor Address (MSHA File)

First Name

Street 2:

Company Address (Item 1)
Miner Requested Send to Address (Item 10)

City:

State:

Zip:

MI

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

MSHA Form 5000-1, January 2008 (Revised -- Previous Editions are Obsolete)

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

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Instructions for Completing MSHA Form 5000-1
Item 1. Company Name and Address
If in Item 8 on the form, Company Address is selected the full name and address of the company is required. 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 selected then this becomes a required field. MSHA is no longer using miscellaneous Mine Id’s or Contractor ID’s example: XX77003 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 MSHA Individual Identification Number (MIIIN) (REQUIRED)
The MIIN number is an MSHA assigned number that all individuals must obtain to be used for training submissions to MSHA and also when
contacting MSHA to verify records. If you need to obtain a MIIN please contact the Qualification and Certification Unit at 303-231-5472 or
800-579-2647.
Item 5. Name of the County and State Where Training Took Place (REQUIRED)
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 by MSHA or MSHA is reinstating the qualification)
This field is MSHA use only.
Item 7. Date Training Completed (REQUIRED)
The date the training was completed
Item 8. Individual Receiving Training MSHA Individual Identification Number (MIIN)
The MIIN number is an MSHA assigned number that all individuals must obtain to be used for training submissions to MSHA and also when
contacting MSHA to verify records. If you need to obtain a MIIN please contact the Qualification and Certification Unit at 303-231-5472 or
800-579-2647.
Choice Where to Mail Cards (REQUIRED)
If Mine Address is selected Item 2 becomes Required.
If Contractor Address is selected Item 2 becomes Required.
If Company Address is selected Item 1 becomes Required.
If Miner Requested Send to Address is selected Item 10 becomes Required.
Item 9. Name (REQUIRED)
The Last Name, First Name, Middle Initial of the individual receiving training
Item 10. Miners Requested Send To Address
If the individual receiving training would like the Electrical Qualification Cards sent to a different address.
Required if Miner requested Send to Address is selected in Item 8.
Item 11. Electrical Codes (Some or all codes are 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 Qualifications. An AR/ROE number is
required in Item 6 to process these codes.
RU – Reinstatement Underground
RS – Reinstatement Surface
Item 13. Signature of Instructor (REQUIRED)
The signature of the Instructor mentioned 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, DFC
Denver, CO. 80225
Phone (303) 231-5472
Toll Free (800) 579-2647
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 certifications/qualifications sought and for MSHA to maintain records 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 applications.
MSHA Form 5000-1, January 2008 (Revised -- Previous Editions are Obsolete)

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