MSHA Form xxxx Participate Demographic Information Collection Form

PARTICIPANT DEMOGRAPHIC INFORMATION COLLECTION FORM (MSHA Form XXXX) OMB Approval No. 1219-xxxx

U.S. DEPARTMENT OF LABOR Expiration Date: xx/20xx

Mine Safety and Health Administration Estimated Burden: 3 minutes

The collected information will be used to enhance MSHA’s understanding of how the Agency’s grant programs are delivered to the mining industry. The demographic information collected will allow MSHA to focus its training and resources on making mines safe and healthy workplaces.

Participants: Please submit the form to your instructor. Your participation is optional. The information you provide below will be confidential and will be used only at an aggregate level. No individual information will be shared with MSHA or other entities or individuals. The form is also available in Spanish.

Item 1. Title of Course:

Item 2. Age (Select one)

____ 24 years and younger

____ 25-34 years

____ 35-44 years

____ 45-54 years

____ 55-64 years

____ 65 years and over

____ Decline to Answer

Item 3. Gender (Select one) The gender markers used are “M” (male), “F” (female), and “X” (transgender, non-binary, or another gender). Mark all that apply.

____ M

____ F

____ X

____ Decline to Answer

Item 4. Race and/or Ethnicity (Select all that apply )

____ American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

____ Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

____ Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

____ Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

____ Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

____ Native Hawaiian or Other Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

____ White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

____ Decline to Answer

Item 5. Primary Language

How well do you speak English?

____Very well ____Well ____Not well ____Not at all

Do you speak a language other than English at home?

____Yes ____No

For persons speaking a language other than English (answering yes to the question above):

What is this language?

____Spanish ____Other Language (Identify) ______

____ Decline to Answer

Instructions for Completing MSHA Form XXXX

Please Print Legibly

Item 1. Title of the Course:

The participant will fill in this item for each training. These trainings are those identified in 30 CFR Parts 46, 48, and 49; training required for certifications or qualifications such as certified mine foreman or a qualified person to test for air flow in 30 CFR Part 75.100; or other trainings provided such as 30 CFR Parts 75.1504 or 57.5070.

The list of training offered including the following:

Part 46: Training and Retraining of Miners Engaged in Shell Dredging or Employed at Sand, Gravel, Surface Stone, Surface Clay, Colloidal Phosphate, or Surface Limestone Mines.

Part 48: Training and Retraining of Miners

Part 49: Mine Rescue Teams

Part 75.100: Certified Person

Part 75.1504: Mine emergency evacuation training and drills

Part 57.5070: Miner Training

Item 2. Age

Age group of the individual receiving the training.

Item 3. Gender

An individual is to self-identify.

Item 4. Race and/or Ethnicity

American Indian or Alaska Native. Individuals with origins in any of the original peoples of North, Central, and South America, including, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, and Maya.

Asian. Individuals with origins in any of the original peoples of Central or East Asia, Southeast Asia, or South Asia, including, for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, and Japanese.

Black or African American. Individuals with origins in any of the Black racial groups of Africa, including, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali.

Hispanic or Latino. Includes individuals of Mexican, Puerto Rican, Salvadoran, Cuban,

Dominican, Guatemalan, and other Central or South American or Spanish culture or origin.

Middle Eastern or North African. Individuals with origins in any of the original peoples of the Middle East or North Africa, including, for example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli.

Native Hawaiian or other Pacific Islander. Individuals with origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands, including, for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, and Marshallese.

White. Individuals with origins in any of the original peoples of Europe, including, for example, English, German, Irish, Italian, Polish, and Scottish.

Item 5. Primary language

The standard for primary language is a measure of English proficiency. The answer to this Item will assist MSHA and its grantees to ensure that training is effective for all participants.

PRIVACY NOTICE

MSHA is collecting personal information such as age, gender, race and/or ethnicity and primary language on this form. This information is used as necessary to plan for federal agencies in their separate or combined format for civil rights and other compliance reporting from the public and private sectors and all levels of government, and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies. By collecting this demographic data, MSHA is identifying barriers for underserved communities to have access safe and healthy jobs in the mining industry through its grantees’ training and compliance assistance programs.

PAPERWORK REDUCTION ACT

Form Approved. OMB No. 1219-xxxx Expires xx/xx/20xx

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. This information is being collected so that MSHA can monitor grantee progress in meeting grant workplans to evaluate the overall effectiveness of the grant program, and, when applicable, to be used as one factor in determining continued funding of the grant. The grant program provides training for individuals, miners, employers, and contractors in the recognition, avoidance, and prevention of unsafe and unhealthful working conditions in accordance with section 503 of the Federal Mine Safety and Health Act of 1977 (Mine Act), Public Law 95-164 as amended, 30 U.S.C. 953 and section 14 of the Mine Improvement and New Emergency Response Act of 2006 (MINER Act), 30 U.S.C. 965. This collection of information is required to obtain or retain a benefit (2 CFR 200.329 (b) and (c)). This collection of information is not confidential. We estimate it will take an average of 3 minutes to complete this information collection, including time for reviewing instructions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Educational Policy and Development, Mine Safety and Health Administration, 201 12th St S, 4^th Floor West, Arlington, VA 22202-5450.

Version #3 May 2024