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MSHA-Forms and Online Filings

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; 12/31/2013
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 5000-1, 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 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.
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