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SCSR Inventory and Report 

OMB Control No. 1219-0141 Expires 12/31/2025

INSTRUCTIONS: This form is for Operators’ use in providing MSHA with complete SCSR inventories as well as in reporting 

problems with SCSRs. Operators may attach continuation sheets to this form provided all required SCSR information is included. Enter 

date information is being reported, MSHA- issued mine ID, name mine is operating under, company name, address of mine, contact 

name and telephone number. Select the manufacturer/model, enter date of manufacture, serial number and report date. If “Other MSHAapproved SCSR _____” is selected, write in the manufacturer/model. The use of this form is voluntary in complying with 75.1714-8. 

A false statement or representation is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act, as 

amended (30 U.S.C. § 820(a) and (f)). 

Report Date E-mail: : 

Mine ID Mine Name: : 

(MSHA Mine ID) 

Company Name: Address:

(Street, P.O.) 

City State Zip 

Contact name: Telephone:

Create list below or attach to this form 

Manufacturer/Model (Pick List) Date of Manufacture Serial Number In/Out Reason (Pick List)

If reporting an SCSR out of inventory, identify the SCSR and enter reason number above.

Send this form to: 

Mine Safety and Health Administration 

Approval & Certification Center

ATTN: SCSR Coordinator 

765 Technology Drive

Triadelphia, WV 26059

Purpose: 30 CFR 75.1714-8 authorizes the collection of this information. MSHA maintains an inventory of all reported SCSR information to assure 

the effectiveness of evacuation plans and emergency evacuations. In addition, such an inventory will assist in targeting SCSR recalls to specific mines. 

The use of this form will facilitate SCSR inventory information transfer from mine operators to MSHA. MSHA may not sponsor or endorse products. 

Burden Statement: Public reporting burden for this collection of information is estimated from 2 hours to 6 hours depending on the size of the mine per 

response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and 

reviewing the collection information. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control 

Number. The DOL offers no pledge of confidentiality in association with these information collections. As a practical matter, the DOL would only release 

this information in accordance with the provisions of the Freedom of Information Act (5 U S.C. § 552); the Privacy Act (5 U.S.C. § 552a); and attendant 

regulations, 29 C.F.R. parts 70 and 71. Send comments regarding this burden estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden, to: Office Standards, Regulations and Variances, Mine Safety and Health Administration, 201 12th Street South, 

Suite 401, Arlington, VA 22202-5452. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. 

MSHA Form 2000-222 (rev. Jun. 2017) (Send to: address changed) Print Form Reset Form