View Information Collection (IC)

View Information Collection (IC)

IC Title:	49.17/ MSHA Form 5000-3	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 49.17

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	MSHA Form 5000-3	Certificate of Physical Qualification for Mine Rescue Work	5000-3 CERT of Physical Qualification for Mine Rescue Work (FILLABLE).pdf	http://www.msha.gov/forms/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable
Form and Instruction	MSHA FORM 5000-3	Certificate of Physical Qualification for Mine Rescue Work (Intro Screen)	MSHA Form 5000-3 Intro Screen.pdf	http://www.msha.gov/forms/elawsforms/5000-3.htm	Yes	Yes	Fillable Fileable

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: 128	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	896	0	0	-336	0	1,232
Annual IC Time Burden (Hours)	224	0	0	-84	0	308
Annual IC Cost Burden (Dollars)	268,800	0	0	-39,200	0	308,000

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.