The current MSHA Form 5000-23 has an expiration date of July 31, 2014, however, previously issued forms with an earlier expiration date may still be used. The printed version comes with four copies. Listed below are notations, which appear on the bottom right-hand side of the form, showing the intended use of each copy:
- Copy 1 (white) - Employer's Personnel Record
Copy 2 (pink) - Employee's Record Copy
Copy 3 (yellow) - Employee's Separation Copy
Copy 4 (green) - Record Keeping
(for operator's use)
|This is an optional field which may be used to help track employees by an identification number. There is no Federal requirement to use this field.|
|Item 1. Print Full Name of Person Trained
(first, middle, last)
|Enter the person's name who has received the training.|
|Item 2. Check Type of Approved Training Received||There are five boxes for the five types of training required. Check the appropriate box(es) to indicate what training was given.
When New Task is checked, additional space is provided to record 1-8 task training events. This space is used to identify each task and to allow for the initials of the instructor(s) and the student (miner), as needed.
|Item 3. Check Type of Operation and Related Industry||(1) Mark the box for the appropriate commodity: coal, metal or nonmetal. (2) Mark the box for the appropriate location: surface or underground. (3) Mark the appropriate box if the training is for construction or shaft and slope work. When completed the box should identify the type of mining, location and if construction or shaft and slope activities are involved.|
|Item 4. Date Training Requirements Completed||Depending on whether the training is complete or partial will determine how this item is completed. Only entering a date indicates that the training marked in item 2 is completed.
Placing a check in the box to the right of the date entry, indicates that the training for the program(s) marked in item 2 is not complete. The appropriate boxes in item 5 must then be checked to indicate what subjects were completed.
The following are some examples of partially completed training: (1) training for new miners given away from the mine site (which will then require site specific training at the mine site); (2) utilizing the 8 and 16 hours of new miner training within 60-day provision for new surface miners; and (3) providing partially completed annual refresher training.
|Item 5. Check Subjects Completed
(use only for partially completed training)
|This is generally used for conducting annual refresher training in increments throughout an annual refresher cycle; or for new miner training which does not cover mine specific courses that are required to be covered at the mine site.|
|Item 6. Signature of person responsible for training||Upon completion of an MSHA approved training program, such as experienced miner, task, or annual refresher training, you must record and certify on the 5000-23 form that the miner has received the specified training.
The person signing the form in item 6 is representing that the miner has received the indicated training. Anyone falsifying the 5000-23 form is criminally liable under section 110(a) and (f) of the Federal Mine Safety and Health Act.
Generally, the person signing the form is the mine operator or a person acting on behalf of the operator. For example, a company safety official, a trainer employed or contracted by the operator, or a cooperative instructor (such as, a state grantee).
|Item 7. Mine Name, ID, & Location of Training
(if institution, give name & address)
|List the mine name, mine ID and location where training was conducted. If the training was conducted by a cooperative instructor or state grantee and a class participant is not employed at a particular mine, fill in the cooperative instructor's name or state name and address.|
|Item 8. Date and (signature of person trained)||The person trained has the option of signing and dating the form, acknowledging that the training indicated on the form was received.
A copy of the 5000-23 form must be given to the miner upon completion of each MSHA approved training program, such as experienced miner, task, or annual refresher training.