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MSHA - Protecting Miners'
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Instructions for Completing a Mine Safety and Health
Administration
Certificate of Training Form (5000-23)

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

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

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

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

ITEM

DESCRIPTION.

Serial Number
(for
operator's use)

This is an optional field which may be used
to help track employees by an identification number. There is no
Federal requirement to use this field.

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

Enter the person's name who has received
the training.

Item 2. Check Type of Approved
Training Received

There are five boxes for the five types of
training required. Check the appropriate box(es) to indicate what
training was given.

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

Item 3. Check Type of Operation and
Related Industry

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

Item 4. Date Training Requirements
Completed

Depending on whether the training is
complete or partial will determine how this item is completed. Only
entering a date indicates that the training marked in item 2 is
completed.

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

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

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

This is generally used for conducting
annual refresher training in increments throughout an annual
refresher cycle; or for newly employed inexperienced miner training
which does not cover mine specific courses that are required to be
covered at the mine site.

Item 6. Signature of person
responsible for training

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

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

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

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

List the mine name, mine ID and location
where training was conducted. If the training was conducted by a
cooperative instructor or state grantee and a class participant is
not employed at a particular mine, fill in the cooperative
instructor's name or state name and address.

Item 8. Date and (signature of
person trained)

The person trained has the option of
signing and dating the form, acknowledging that the training
indicated on the form was received.

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

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