Msha Form 2000-222 - Scsr Inventory And Report

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SCSR Inventory and Report

U.S. Department of Labor

Mine Safety and Health Administration

OMB Control No. 1219-0141 (Expires 8/31/2016)

INSTRUCTIONS: This form is for Operators’ use in providing MSHA with complete SCSR inventories as well as in reporting

problems with SCSRs. Operators may attach continuation sheets to this form provided all required SCSR information is included. Enter

date information is being reported, MSHA- issued mine ID, name mine is operating under, company name, address of mine, contact

name and telephone number. Select the manufacturer/model, enter date of manufacture, serial number and report date. If “Other MSHA-

approved SCSR ____” is selected, write in the manufacturer/model. The use of this form is voluntary in complying with 75.1714-8.

A false statement or representation is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act, as

amended (30 U.S.C. § 820(a) and (f)).

Report Date:____________________

E-mail:____________________

Mine ID: __________________

Mine Name: ______________________________________

(MSHA Mine ID)

Company Name:__________________________

Address: __________________________________________

(Street, P.O.)

_________________________________________________

City

State

Zip

Contact name: __________________________

Telephone:____________

Check all that apply

Create list below or attach to this form

Manufacturer/Model

Date of Manufacture

Serial Number

In/Out

Reason

⁭ CSE SR-100

_________________

____________

⁭ ⁭

________

⁭ OCENCO EBA 6.5

_________________

____________

⁭ ⁭

________

⁭ OCENCO M20

_________________

____________

⁭ ⁭

________

⁭ DRAEGER OXY-K Plus

________________

____________

⁭ ⁭

________

⁭ DRAEGER OXY-K Plus S

_________________

____________

⁭ ⁭

________

⁭ MSA LIFE-SAVER 60

_________________

____________

⁭ ⁭

________

⁭ Other MSHA-approved SCSR_______

_________________

____________

⁭ ⁭

________

If reporting an SCSR out of inventory, identify the SCSR and enter reason number above:

1) Out for Refurbishment

2) Damaged/Not Repairable

3) Out of Date

4) Missing

5) Transferred

6) Used/Activated

7) Data Entry Error

Mine Safety and Health Administration

Send this form to:

Technical Support

Pittsburgh Safety and Health Technology Center

Attn: SCSR Coordinator

Cochrans Mill Road

P.O. Box 18233

Pittsburgh, Pennsylvania 15236

Purpose: 30 CFR 75.1714-8 authorizes the collection of this information. MSHA maintains an inventory of all reported SCSR information to assure the

effectiveness of evacuation plans and emergency evacuations. In addition, such an inventory will assist in targeting SCSR recalls to specific mines. The

use of this form will facilitate SCSR inventory information transfer from mine operators to MSHA. MSHA may not sponsor or endorse products.

Burden Statement: Public reporting burden for this collection of information is estimated from 2 hours to 6 hours depending on the size of the mine per

response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and

reviewing the collection information. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control

Number. The DOL offers no pledge of confidentiality in association with these information collections. As a practical matter, the DOL would only release

this information in accordance with the provisions of the Freedom of Information Act (5 U.S.C. § 552); the Privacy Act (5 U.S.C. § 552a); and attendant

regulations, 29 C.F.R. parts 70 and 71. Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: Office Standards, Regulations and Variances, Mine Safety and Health Administration, 201 12th Street South,

Suite 401, Arlington, VA 22202-5452. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

MSHA Form 2000-222 (Rev. Aug. 2015) (Previous versions are usable.)