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Form number: MSHA Form 5000-3
Form name: Certificate of Physical Qualification for Mine Rescue Work
Description: Title 30, CFR § 49 requires the mine operator of an underground mine to establish at least two mine rescue teams to be available at all times that miners are underground, or the operator must enter into an arrangement for mine rescue services which assures that at least two teams are available at all times when miners are underground.

Under Title 30, CFR § 49.7, each mine rescue team member must be examined by a physician annually, with the first examination being completed within 60 days prior to scheduled initial training. An MSHA Form 5000-3 for each team member must be completed and signed by the examining physician. These forms shall be kept on file at the mine rescue station for a period of one year.
OMB Control Number and
Expiration Date:
1219-0078 and 1219 0144; Approval Expires 12/31/2016
Filing Options: Form 5000-3 should be printed and filled in manually. This form must be completed and signed by the examining physician for each member of a mine rescue team. These forms shall be kept on file at the mine rescue station for a period of 1 year.

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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 49.7
Burden Statement: Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety and Health Administration, U.S. Department of Labor, Office of Standards, Regulations and Variances, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
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