Please wait... If this message is not eventually replaced by the
proper contents of the document, your PDF viewer may not be able to
display this type of document. You can upgrade to the latest
version of Adobe Reader for Windows®, Mac, or Linux® by visiting
http://www.adobe.com/go/reader_download. For more assistance with
Adobe Reader visit http://www.adobe.com/go/acrreader. Windows is
either a registered trademark or a trademark of Microsoft
Corporation in the United States and/or other countries. Mac is a
trademark of Apple Inc., registered in the United States and other
countries. Linux is the registered trademark of Linus Torvalds in
the U.S. and other countries.
MSHA - Forms - 5000-1 Certificate of Electrical Training
DOL - Mine Safety and Health Administration
9.0.0.2.20120627.2.874785
MSHA Form 5000-1, Aug. 2015 rev. (Mailing
Address)
Page 1 of 3
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 1219-0001. Approval Expires January
31, 2023
Item 1.
Company Name and Address (if the address below is blank,
Item 2.
Mine ID or Contractor ID
Item 7.
Date Completed (MM/DD/YYYY)
information will be sent to address selected in Item 8.)
C
o
m
p
a
n
y
N
a
m
e
Item 3.
Instructor Name
Attn:
Item 4.
Instructor’s MSHA Individual Identification Number (MIIN)
S
t
r
e
e
t
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.
Item 11.
MSHA
Electrical Codes Use Only
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, 201 12th
Street South, Suite 401., Arlington, VA 22202-5452, 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 9.
Name (Last, First, M)
Item 10.
Miner Requested Send To Address
Underground Initial (EB)
Surface Initial (ED)
Underground Retraining (EC)
Surface Retraining (EE)
Underground Reinstatement
(RU)
Surface Reinstatement (RS)
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
1
2
3
MSHA Form 5000-1, Aug. 2015 rev. (Mailing Address)
Page 2 of 3
Certificate of Electrical Training
U.S. Department of Labor
Mine Safety and Health Administration
R
e
t
u
r
n
t
o
:
Underground Initial (EB)
Surface Initial (ED)
Underground Retraining (EC)
Surface Retraining (EE)
Underground Reinstatement
(RU)
Surface Reinstatement (RS)
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
MIIN
Mine Address (MSHA File)
Contractor Address (MSHA File)
Company Address (Item 1)
Miner Requested Send to Address (Item 10)
Last Name
First Name
MI
Attn:
Street 1:
Street 2:
City: State: Zip:
EB
ED
EC
EE
RU
RS
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)
Item 13.
Signature for Instructor (I certify that the above individuals
have completed the course/s indicated)
MSHA Qualification & Certification Unit
P.O. Box 25367, DFC
Denver, CO. 80225
Phone: (303) 231-5472
Fax: (303) 231-5474
4
5
6
7
8
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:
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 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, Aug. 2015 rev. (Mailing
Address)
Page 3 of 3
CompanyName: CompanyAttn: CompanyStreet1: CompanyStreet2:
CompanyCity: CompanyState: CompanyZip: MIDorCID: CompletedDate:
CountyofTraining: StateofTraining: ARROE: MIINMiner1: :
LastNameMiner1: FirstNameMiner1: MiddleNameMiner1: AttnMiner1:
Street1Miner1: Street2Miner1: CityMiner1: StateMiner1: ZipMiner1:
EBMiner1: OffEDMiner1: OffECMiner1: OffEEMiner1: OffRUMiner1:
OffRSMiner1: OffMIINMiner2: LastNameMiner2: FirstNameMiner2:
MiddleNameMiner2: AttnMiner2: Street1Miner2: Street2Miner2:
CityMiner2: StateMiner2: ZipMiner2: EBMiner2: OffEDMiner2:
OffECMiner2: OffEEMiner2: OffRUMiner2: OffRSMiner2: OffMIINMiner3:
LastNameMiner3: FirstNameMiner3: MiddleNameMiner3: AttnMiner3:
Street1Miner3: Street2Miner3: CityMiner3: StateMiner3: ZipMiner3:
EBMiner3: OffEDMiner3: OffECMiner3: OffEEMiner3: OffRUMiner3:
OffRSMiner3: OffMIINMiner4: LastNameMiner4: FirstNameMiner4:
MiddleNameMiner4: AttnMiner4: Street1Miner4: Street2Miner4:
CityMiner4: StateMiner4: ZipMiner4: EBMiner4: OffEDMiner4:
OffECMiner4: OffEEMiner4: OffRUMiner4: OffRSMiner4: OffMIINMiner5:
LastNameMiner5: FirstNameMiner5: MiddleNameMiner5: AttnMiner5:
Street1Miner5: Street2Miner5: CityMiner5: StateMiner5: ZipMiner5:
EBMiner5: OffEDMiner5: OffECMiner5: OffEEMiner5: OffRUMiner5:
OffRSMiner5: OffMIINMiner6: LastNameMiner6: FirstNameMiner6:
MiddleNameMiner6: AttnMiner6: Street1Miner6: Street2Miner6:
CityMiner6: StateMiner6: ZipMiner6: EBMiner6: OffEDMiner6:
OffECMiner6: OffEEMiner6: OffRUMiner6: OffRSMiner6: OffMIINMiner7:
LastNameMiner7: FirstNameMiner7: MiddleNameMiner7: AttnMiner7:
Street1Miner7: Street2Miner7: CityMiner7: StateMiner7: ZipMiner7:
EBMiner7: OffEDMiner7: OffECMiner7: OffEEMiner7: OffRUMiner7:
OffRSMiner7: OffMIINMiner8: LastNameMiner8: FirstNameMiner8:
MiddleNameMiner8: AttnMiner8: Street1Miner8: Street2Miner8:
CityMiner8: StateMiner8: ZipMiner8: EBMiner8: OffEDMiner8:
OffECMiner8: OffEEMiner8: OffRUMiner8: OffRSMiner8: Off