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SAMPLE Templates and Checklists

The sample templates and checklists listed on this page were provided by stakeholders to assist others in complying with MSHA’s working place exam rule for metal and nonmetal mines.  If you wish to submit other samples of templates or checklists or similar compliance aids for MSHA review and potential posting, please send your materials to:

Don Vickers
Metal and Nonmetal Safety Division

SAMPLE 1 model workplace exam form requirements only

SAMPLE 2a Examination of Working Places DEMO (4.0)

SAMPLE 2b Examination of Working Places DEMO (4.0) SAMPLE


SAMPLE 4 Workplace Exam Record Form

SAMPLE 5 Workplace Exam Record Form C