1. Task Initials
Instr_ Studt
8. Date
Co - Employer's Personnel RecordMSHA Form 5000-23, Jan. 99 (revised)
Certificate of Training U.S. Department of Labor
Mine Safety and Health Administration
Approved OMB Number 1219-0009, Expires July 31, 2014.
This certificate is required under Public Law 91-173 as amended by Public Law 95-164.
Failure to comply may result in penalties and other sanctions as provided by sections 10
and 110, Public Law 91-173 as amended by Public Law 95-164.
A Issue Certificate Immediately Serial Number (for operator's use)
Upon Completion of Training 29 06
1. Print Full Name of Person Trained (first, middle, last)
gEv-zo D. 1.-oseKE2. Check Type of Approved Training Received:
ly' Annual E Experienced Miner
Refresher
D New Task
(specify below)
Date Task Initials Date
!mil- Studt___—
__---
3. Check Type of Operation and Related Industry:
A. $ Surface X Construction
B. NI Coal X Metal
4. Date Training Requirements Completed
3/10/g)1.5
4 If completed, go to item 6, below.
111 Newly Employed,
Inexperienced Miner
5. Check Subjects Completed (use only for partially completed training):
u Introduction to Work Environment
u Hazard Recognition
u Emergency Medical Procedures
u H&S Aspects of Tasks Assigned
u Statutory Rights of Miners
u Self-Rescue & Respiratory Devices
1:1 Transport & Communication Systems
6. False certification is punishable under
section 110 (a) and (f) of the Federal Mine
Safety & Health Act (P. L. 91-173 as
amended by P. L. 95-164).
I certify that the above training has been completed
(signature of person responsible for training
7. Mine Name, ID, & Location of Training (if instit ion, give name & address)
Mine Safety & Health Program
Colorado School of Mines
Golden CO 80401
I verify that I h
(signature of pers
e above training
111 Hazard Training
Other (specify)
u Underground u Shaft & Slope
Nonmetal
u Check if not completed
and go to item 5, below.
Roof/Ground Control
& Ventilation
u Mine Map; Escapeways;
Emergency Evacuation;
Barricading
u Cleanup; Rock Dusting
u Mandatory Health &
Safety Standards
u Authority & Responsibility
of Supervisors & Miners'
Representatives
u Health
u Electrical Hazards
u First Aid
u Mine Gases
u Explosives
u Prevention of Accidents
u Other (specify)
3/142015