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

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

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

Form Approved: OMB Number 1219-0001. Approval Expires October 31, 2013

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

Last Name

1

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

2

Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
MIIN

3

Street 1:

First Name

City:

MI

EE

RU

RS

EB

ED

EC

EE

RU

RS

EB

ED

EC

EE

RU

RS

Zip:

Street 2:

First Name

City:

MI

State:

Zip:

Attn:
Street 1:
Street 2:

First Name

Company Address (Item 1)

MSHA Form 5000-1, Revised April 2013

State:

Street 1:

Mine Address (MSHA File)

Miner Requested Send to Address (Item 10)

EC

Attn:

Last Name
Contractor Address (MSHA File)

ED

Street 2:

Last Name

MIIN

EB

Attn:

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

Surface Reinstatement (RS)

MIIN

Item 10. Miner Requested Send To Address

Underground Reinstatement
(RU)

Item 9. Name (Last, First, M)

Surface Retraining (EE)

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 form is estimated to average 25 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and submitting the form. This collection of information is mandatory. You are not required to respond to this collection of information unless it displays a valid
OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: to the Mine Safety and Health Administration, U.S. Department of Labor,
Office of Standards Regulations and Variances, 1100 Wilson Blvd., Arlington, VA 22209, Paperwork Reduction Project (1219-0001). NOTE: Do not send your completed form to this address.

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

Item 12.
MSHA
Use Only

Item 11.
Electrical Codes
Underground Retraining (EC)

Zip

Surface Initial (ED)

State

Underground Initial (EB)

City

City:

MI

Page 1 of 3

State:

Zip:

Street 2:

First Name

Company Address (Item 1)

MIIN

5

City:

MI

6

First Name

City:

MI

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

Zip:

First Name

City:

MI

State:

Zip:

Attn:

MIIN

Last Name

Street 1:

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

Street 2:

First Name

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

8

RU

Street 2:

Company Address (Item 1)

7

State:

Street 1:

Mine Address (MSHA File)

Miner Requested Send to Address (Item 10)

EE

Attn:

Last Name
Contractor Address (MSHA File)

EC

Zip:

Street 2:

Company Address (Item 1)

MIIN

State:

Street 1:

Mine Address (MSHA File)

Miner Requested Send to Address (Item 10)

ED

Attn:

Last Name
Contractor Address (MSHA File)

Surface Reinstatement (RS)

Street 1:

Mine Address (MSHA File)

Miner Requested Send to Address (Item 10)

EB

Attn:

Last Name
Contractor Address (MSHA File)

Underground Reinstatement
(RU)

4

Surface Retraining (EE)

MIIN

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

City:

MI

Street 1:

Mine Address (MSHA File)

Street 2:

First Name

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

City:

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, Revised April 2013

Zip:

Attn:

Last Name
Contractor Address (MSHA File)

State:

State:

Zip:

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, Revised April 2013

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