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MSHA-Forms and Online Filings

Form number: MSHA Form 5000-41
Form name: Safety and Health Activity Certification or Hoisting Engineers Qualification Request Form
Description: All instructors are required to submit to MSHA the names of persons who have satisfactorily completed required mine foreman and pre-shift examiner or hoisting certification training. The 5000-41 is a combined version of the previous 5000-4 and 5000-7 forms. MSHA uses the form information to issue certification cards to qualified persons.
OMB Control Number and
Expiration Date:
1219-0127; 9/30/2014
Filing Options: Form 5000-41, Health Activity Certification or Hoisting Engineers Qualification Request Form can be either filed online or printed, filled in and sent to MSHA according to the instructions below.

File online
Form fill, print and mail or fax
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Filing Instructions: Detailed instructions for filing Form 5000-41, Health Activity Certification or Hoisting Engineers Qualification Request Form 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 75.100, 30 CFR 77.100 (Health and Safety Certification) establish the procedures under which miners are certified to make certain tests and examinations which are required by MSHA regulations to be performed by certified persons. For mines located in states that do not have provisions for certifying miners, 30 CFR 75.100 (c) (1) and 30 CFR 77.100 (b) (2) require mine operators to make application to MSHA to obtain certification for miners who meet certain minimum experience requirements. A certified person is one who has been certified as a Foreman, Assistant Foreman (UG only), or Pre-shift Examiner (UG only).

30 CFR 75.155 and 30 CFR 77.105 (Hoisting Engineers Qualification) establish the procedures under which miners are qualified to operate hoists (Steam Driven/Electrical-UG; Slope & Shaft Sinking Operation-Sur). For mines located in states that do not have provisions for qualifying hoist operators, 30 CFR 75.155/77.105 requires mine operators to apply to MSHA to obtain qualification for miners who meet certain minimum experience requirements.
Burden Statement: Public reporting burden for this form is estimated to average 10 minutes per response for the electronic version and 17 minutes per response for the hard copy. 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 DOL/MSHA, Office of Standards Regulations and Variances, 1100 Wilson Blvd., Arlington, VA 22209, Paperwork Reduction Project (1219-0127).
NOTE: Do not send your completed form to this address.
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