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Forms and Online Filings

Form number:

MSHA Form 5000-1

Form name:

Certificate of Electrical/Noise Training


All instructors are required to submit to submit to MSHA the names of persons who have satisfactorily completed required electrical training. MSHA uses the form information to issue certification cards to those persons who are qualified.

OMB Control Number and Expiration Date:

1219-0001; 6/30/2013

Filing Options:

Form 5000-1, Certificate of Electrical/Noise Training can be filed online or completed online, printed (or printed and filled in manually) and sent to MSHA according to the instructions provided below.

File Online
Fill in online, print and mail or fax (or print and fill in manually)

Filing Instructions:

If filing by mail or fax, completed printed forms should be sent to:

MSHA Qualification and Certification
P.O. Box 25367
Denver, Colorado 80225-0367
Fax: (303) 231-5474

Contact Information:

Questions regarding this form should be directed to MSHA at (877) 778-6055 or

Privacy Notice:

Privacy Notice

Legal Authority:

30 CFR 75.153(g) and 77.103(g) require that an individual who is a qualified electrical person in accordance with Section 75.153 and 77.103 shall annually certify to the district manager that he has satisfactorily completed a coal mine electrical retraining program approved by the Secretary in order to retain that qualification.

Burden Statement:

Public reporting burden for this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data need, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Information Management, Department of Labor, Room N-1301, 200 Constitution Avenue, N.W., Washington, D.C. 20210; and to the Office of Management and Budget, Paperwork Reduction Project (1219-0001), Washington, D.C. 20503. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

Complete and File Form Online

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