MSHA: Instructions for Completing MSHA = Training Form 5000-23

Mine Safety and Health=20 Administration

MSHA - Protecting = Miners'=20 Safety and Health Since 1978

= Help=20 Printing This Page

Instructions for Completing a Mine Safety = and Health=20 Administration
Certificate of Training Form = (5000-23)

All part 48 training must be properly recorded on a Mine Safety = and=20 Health Administration (MSHA) Form 5000-23 (training certificate), = or on an=20 MSHA approved alternate form. For additional policy information on = the=20 5000-23 form, you may refer to the MSHA Program Policy Manual. To = review=20 the applicable policy please use this=20 link.

The current MSHA Form 5000-23 has an expiration date of July = 31, 2014,=20 however, previously issued forms with an earlier expiration date = may still=20 be used. The printed version comes with four copies. Listed below = are=20 notations, which appear on the bottom right-hand side of the form, = showing=20 the intended use of each copy:

Copy 1 (white) - Employer's Personnel Record
Copy 2=20 (pink) - Employee's Record Copy
Copy 3 = (yellow) -=20 Employee's Separation Copy
Copy 4 (green) - Record = Keeping

The following is a description of how to complete each item of = the=20 5000-23.

ITEM DESCRIPTION.

Serial Number
(for=20 operator's use) This is an optional field which = may be used=20 to help track employees by an identification number. There = is no=20 Federal requirement to use this = field.

Item 1. Print Full Name of = Person=20 Trained
(first, middle, = last) Enter the person's name who has = received=20 the training.

Item 2. Check Type of = Approved=20 Training Received There are five boxes for the five = types of=20 training required. Check the appropriate box(es) to indicate = what=20 training was given.

When New Task is checked, = additional=20 space is provided to record 1-8 task training events. This = space is=20 used to identify each task and to allow for the initials of = the=20 instructor(s) and the student (miner), as=20 needed.

Item 3. Check Type of = Operation and=20 Related Industry (1) Mark the box for the = appropriate=20 commodity: coal, metal or nonmetal. (2) Mark the box for the = appropriate location: surface or underground. (3) Mark the=20 appropriate box if the training is for construction or shaft = and=20 slope work. When completed the box should identify the type = of=20 mining, location and if construction or shaft and slope = activities=20 are involved.

Item 4. Date Training = Requirements=20 Completed Depending on whether the training = is=20 complete or partial will determine how this item is = completed. Only=20 entering a date indicates that the training marked in item 2 = is=20 completed.

Placing a check in the box to the right = of the=20 date entry, indicates that the training for the program(s) = marked in=20 item 2 is not complete. The appropriate boxes in item = 5 must=20 then be checked to indicate what subjects were completed.=20

The following are some examples of partially = completed=20 training: (1) training for new miners given away from the = mine site=20 (which will then require site specific training at the mine = site);=20 (2) utilizing the 8 and 16 hours in 60-day provision for = newly=20 employed inexperienced surface miners; and (3) providing = partially=20 completed annual refresher = training.

Item 5. Check Subjects=20 Completed
(use only for partially = completed=20 training) This is generally used for = conducting=20 annual refresher training in increments throughout an annual = refresher cycle; or for newly employed inexperienced miner = training=20 which does not cover mine specific courses that are required = to be=20 covered at the mine site.

Item 6. Signature of = person=20 responsible for training Upon completion of an MSHA = approved=20 training program, such as experienced miner, task, or annual = refresher training, you must record and certify on the = 5000-23 form=20 that the miner has received the specified training. =

The=20 person signing the form in item 6 is representing that the = miner has=20 received the indicated training. Anyone falsifying the = 5000-23 form=20 is criminally liable under section 110(a) and (f) of the = Federal=20 Mine Safety and Health Act.

Generally, the person = signing=20 the form is the mine operator or a person acting on behalf = of the=20 operator. For example, a company safety official, a trainer = employed=20 or contracted by the operator, or a cooperative instructor = (such as,=20 a state grantee).

Item 7. Mine Name, ID, = &=20 Location of Training
(if institution, = give name=20 & address) List the mine name, mine ID and = location=20 where training was conducted. If the training was conducted = by a=20 cooperative instructor or state grantee and a class = participant is=20 not employed at a particular mine, fill in the cooperative=20 instructor's name or state name and = address.

Item 8. Date and = (signature of=20 person trained) The person trained has the option = of=20 signing and dating the form, acknowledging that the training = indicated on the form was received.

A copy of the = 5000-23=20 form must be given to the miner upon completion of each MSHA = approved training program, such as experienced miner, task, = or=20 annual refresher training.=20