Information Collection

Qualification/Certification Program and Man Hoist Operators Physical Fitness

IC 14507 under ICR 200802-1219-003 · OMB 1219-0127.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1219-0127 can be found here:

Documents and Forms

Document Name Document Type
Form 5000-41 Qualification/Certification Program and Man Hoist Operators Physical Fitness Form
5000-41 Health Activity Certification or Hoisting Engineers Qual 5000-41 Safety and Health Activity Certification or Hoisting Engineer Request.pdf www.msha.gov/forms/elawsforms/5000-41.htm Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Qualification/Certification Program and Man Hoist Operators Physical Fitness	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 75.160 30 CFR 77.106 30 CFR 75.155 30 CFR 75.159 30 CFR 75.100 30 CFR 75.161 30 CFR 77.100 30 CFR 77.105 30 CFR 77.107 30 CFR 77.107-1

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5000-41	Health Activity Certification or Hoisting Engineers Qualification Request Form	5000-41 Safety and Health Activity Certification or Hoisting Engineer Request.pdf	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records
Title: DOL/MSHA-15 Health & Safety Training and Examination Records	FR Citation: 67 FR 16815

Number of Respondents: 1,721	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 55 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,432	-8,136	10,568
Annual IC Time Burden (Hours)	15,355	-2,368	17,723
Annual IC Cost Burden (Dollars)	8,047	47	8,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.