Fillable Msha Form 5000-23 - Certificate Of Training printable pdf download

Msha Form 5000-23 - Certificate Of Training

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Certificate of Training

U.S. Department of Labor

Mine Safety and Health Administration

Approved OMB Number 1219-0009, Expires December 30, 2007.

This certificate is required under Public Law 91-173 as amended by Public Law 95-164.

Failure to comply may result in penalties and other sanctions as provided by sections 108

and 110, Public Law 91-173 as amended by Public Law 95-164.

Serial Number (for operator’s use)

Issue Certificate Immediately

Upon Completion of Training

1. Print Full Name of Person Trained (first, middle, last)

2. Check Type of Approved Training Received:

Annual

Hazard Training

Experienced Miner

Refresher

Other (specify)

New Task

Newly Employed,

(specify below)

Inexperienced Miner

Date

Task

Initials

Date

Task

Initials

Instr

Studt

3. Check Type of Operation and Related Industry:

Construction

Underground

Surface

Shaft & Slope

Coal

Metal

Nonmetal

4. Date Training Requirements Completed

Check if not completed

and go to item 5, below.

If completed, go to item 6, below.

5. Check Subjects Completed (use only for partially completed training):

Introduction to Work Environment

Roof/Ground Control

Health

& Ventilation

Hazard Recognition

Electrical Hazards

Mine Map; Escapeways;

Emergency Evacuation;

First Aid

Emergency Medical Procedures

Barricading

Mine Gases

H&S Aspects of Tasks Assigned

Cleanup; Rock Dusting

Explosives

Statutory Rights of Miners

Mandatory Health &

Safety Standards

Prevention of Accidents

Self-Rescue & Respiratory Devices

Authority & Responsibility

Other (specify)

of Supervisors & Miners’

Transport & Communication Systems

Representatives

6. False certification is punishable under

I certify that the above training has been completed

(signature of person responsible for training)

section 110 (a) and (f) of the Federal Mine

Safety & Health Act (P. L. 91-173 as

amended by P. L. 95-164).

7. Mine Name, ID, & Location of Training (if institution, give name & address)

I verify that I have completed the above training

8. Date

(signature of person trained)

MSHA Form 5000-23, Jan. 99 (revised)

Clear Form

Msha Form 5000-23 - Certificate Of Training

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