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Participant Demographic Information Collection Form

Form ID

This optional form will be distributed among training participants by grantees after completing training. The new survey form will ask training participants to identify their age, gender, ethnicity, race, and primary language spoken. This information will be kept confidential (i.e., the responses are not associated with a specific participant) and will only be reported in the aggregate.

Control ID
Expiration Date
Mon, 05/31/2027 - 00:00
Filing Instructions

Please read all instructions that are included with the form.  MSHA does not receive or maintain copies of the 6000-1. DO NOT FILE THIS FORM WITH MSHA.       

Contact Information

Questions regarding this form should be directed to MSHA at (877) 778-6055 or

Privacy Notice

MSHA is collecting personal information such as age, gender, race and/or ethnicity and primary language on this form. This information is used as necessary to plan for federal agencies in their separate or combined format for civil rights and other compliance reporting from the public and private sectors and all levels of government, and in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies. By collecting this demographic data, MSHA is identifying barriers for underserved communities to have access safe and healthy jobs in the mining industry through its grantees' training and compliance assistance programs. 

Burden Statement

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. This information is being collected so that MSHA can monitor grantee progress in meeting grant work plans to evaluate the overall effectiveness of the grant program, and, when applicable, to be used as one factor in determining continued funding of the grant.

The grant program provides training for individuals, miners, employers, and contractors in the recognition, avoidance, and prevention of unsafe and unhealthful working conditions in accordance with section 503 of the Federal Mine Safety and Health Act of 1977 (Mine Act), Public Law 95-164 as amended, 30 U.S.C. 953 and section 14 of the Mine Improvement and New Emergency Response Act of 2006 (MINER Act), 30 U.S.C. 965. This collection of information is required to obtain or retain a benefit (2 CFR 200.329 (b) and (c)). This collection of information is not confidential. We estimate it will take an average of 3 minutes to complete this information collection, including time for reviewing instructions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Directorate of Educational Policy and Development, Mine Safety and Health Administration, 201 12th St. S, 4th Floor West, Arlington, VA 2202-5450. OMB Number 1219-0157, Approval expires 05