Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Mine Rescue Teams; Arrangements for Emergency Medical Assistance; and Arrangements for Transportation for Injured Persons
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
30 CFR 49.3
30 CFR 49.4
30 CFR 49.2
30 CFR 49.5
30 CFR 49.6
30 CFR 49.7
30 CFR 49.8
30 CFR 49.9
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
5000-3
Certificate of Physical Qualification for Mine Rescue Work
5000-3 CERT of Physical Qualification for Mine Rescue Work (OMB).pdf
https://www.msha.gov/support-resources/forms-online-filing/2015/04/15/certificate-physical-qualification-mine-rescue-work
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
202
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
19,973
0
0
-68
0
20,041
Annual IC Time Burden (Hours)
9,941
0
0
-168
0
10,109
Annual IC Cost Burden (Dollars)
309,068
0
0
1
0
309,067
Documents for IC
Title
Document
Date Uploaded
Forms and Filings Intro Page for Form MSHA-5000-3
Certificate of Physical Qualification for Mine Rescue Work.pdf
07/24/2019
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.