Instructions for Completing a
Mine Safety and Health Administration
Health Activity Certification or Hoisting Engineers Qualification
Request Form (5000-41)
Please Print Legibly
Privacy Act Statement
- Item 1. Company Name and Address
The full name and address of the Company should be completely filled in. This is not required if the address selector in Item 4 is not
selected as Company Address.
- Item 2. Mine ID or Contractor ID (Required)
The MSHA assigned MID or CID number must be filled in
- Item 3. MSHA Individual Identification Number (MIIN) (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 4. Address Selector, where the cards are to sent
- If Mine Address is selected the address on file for the MID in Item 2 will receive the cards
- If Contractor Address is selected the address on file for the MID in Item 2 will receive the cards.
- If Company Address is selected Item 1 becomes required.
- If Miner Requested Send to Address is selected Item 6 becomes required.
- Item 5. Name (Required)
Last, First, Middle Initial of individual receiving the qualification or certification
- Item 6. Miner Requested Send to Address
If the individual receiving training would like the qualification or certification card sent to a different address. Required if Miner Requested
Send to Address is selected in Item 4.
- Item 7. Certifications (Required if request is for Activity Certification)
Choose the box designated for the type of certification requested
- Item 8. Qualifications (Required if request is for Hoisting)
Choose the box designated for Hoisting Qualification requested
- Item 9. Type of Hoist (Required if request is for Hoisting)
Choose the box designated for type of Hoist requested.
- Item 10. Signature for Activity Certification Request (Required if request is for Activity Certification)
If a box in Item 7. is selected, the person requesting the individual be given Activity Certification needs to sign.
- Item 11. Date (Required)
The date the Certification is being requested
- Item 12. Signature for Hoisting Qualification (Required if request is for Hoisting Qualification)
If a box in Item 8 is selected, the person requesting the individual be given Hoisting Qualification needs to sign.
- Item 13. Date (Required)
The date the Qualification is being requested
Return form to:
MSHA, Qualification and Certification
P.O. Box 25367
Denver, CO. 80225
Phone (303) 231-5472
Toll Free: (800) 579-2647
Fax: (303) 231-5474
30 CFR 75.100, 77.100, 75.155 and 77.105 authorize the collection of this information. This information will be used to
determine if miners satisfy the requirements to obtain the certification/qualification sought and for MSHA to maintain a record of
these certifications/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 application.