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.
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
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
Questions regarding this form should be directed to MSHA at (877) 778-6055 or desk.help@dol.gov
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.
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, 200 Constitution Avenue, NW, Room C3522, Washington, DC 20210. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. NOTE: Do not send your completed form to this address.