Information Collection

Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties

IC 14507 under ICR 201406-1219-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 MSHA Form 5000-41 Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties Form
Form 5000-41 Intro Screen.pdf www.msha.gov/forms/elawsforms/5000-41.htm Instruction
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41.pdf www.msha.gov/forms/elawsforms/5000-41.htm Form
MSHA Form 5000-41 Safety and Health Activity Certification or Hoisting Eng 5000-41_screenshots.docx www.msha.gov/forms/elawsforms/5000-41.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification and Qualification to Examine, Test, Operate Hoists, and to Perform Other Duties	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 75.159 30 CFR 75.160 30 CFR 77.106 30 CFR 75.100 30 CFR 75.161 30 CFR 77.100 30 CFR 77.105 30 CFR 75.155 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	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41.pdf	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA Form 5000-41	Safety and Health Activity Certification or Hoisting Engineers Qualification Request	5000-41_screenshots.docx	http://www.msha.gov/forms/elawsforms/5000-41.htm	Yes	Yes	Fillable Fileable Signable
Instruction			Form 5000-41 Intro Screen.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: 1,232	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,659	-1,307	6,966
Annual IC Time Burden (Hours)	548	-131	679
Annual IC Cost Burden (Dollars)	71	-54	125

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.