MSHA Form 5000-1 Certificate of Electrical Training

MSHA - Forms and Online Filings - Form 5000-1 - Certificate of Electrical/Noise Training Page 1 of 2

Form number:

MSHA Form 5000-1

Form name:

Certificate of Electrical/Noise Training

Description:

All instructors are required to submit to MSHA
the names of persons who have satisfactorily
completed required electrical training. MSHA
uses the form information to issue certification
cards to those persons who are qualified.

OMB Control
Number and
Expiration Date:

1219-0001; 10/31/2016

Filing Options:

Form 5000-1, Certificate of Electrical/Noise
Training can be filed online or completed online,
printed (or printed and filled in manually) and
sent to MSHA according to the instructions
provided below.
File Online
Fill in, print and mail or fax
Change online filing registration information

Filing
Instructions:

Detailed Instructions for completing Form 50001, Certificate of Electrical/Noise Training 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 MSHAhelpdesk@dol.gov

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 75.153(g) and 77.103(g) require that an
individual who is a qualified electrical person in
accordance with Section 75.153 and 77.103 shall
annually certify to the district manager that he
has satisfactorily completed a coal mine
electrical retraining program approved by the
Secretary in order to retain that qualification.

Burden
Statement:

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

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8/24/2016

MSHA - Forms and Online Filings - Form 5000-1 - Certificate of Electrical/Noise Training Page 2 of 2

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, 201 12th Street South, Arlington, VA
22209, Paperwork Reduction Project (12190001). NOTE: Do not send your completed
form to this address.
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Complete and File Form Online
Return to MSHA Online Forms Advisor Main Menu

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8/24/2016