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Health Activity Certification or Hoisting Engineers Qualification Request

Form ID: 
5000-41
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.

Control ID: 
1219-0127
Expiration Date: 
December 31, 2017
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
Fill in, print and mail or fax
Change online filing registration information

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 desk.help@dol.gov

Privacy Notice: 
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, 201 12th Street South, Suite 401 Arlington, VA 22202-5450, Paperwork Reduction Project (1219-0127). 
NOTE: Do not send your completed form to this address.