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Form 5000-41 Disclaimer
(Health Activity Certification or Hoisting Engineers Qualification Request Form)

This is a voluntary collection of information (30 CFR 75.100, 75.155, 77.100 and 77.105). Form 5000-41 allows mining operators to report to MSHA the names of persons who have satisfactorily completed required mine foreman, and hoisting training. MSHA uses the form information to issue certification/qualification cards to those persons who are certified/qualified. This information is used to identify a person or organization designated as a certified mine forman/preshift examiner. Any personal information (e-mail or otherwise) submitted is used for contact purposes only. This personal information is not used or distributed to any other agency or used for any other purpose.