MSHA Form 5000-23 

May 2021 (revised)

Page 1 of 5

U. S. Department of Labor 

Mine Safety and Health Administration

Certificate of Training 

MSHA Form 5000-23, May 2021 (revised)

Persons are not required to respond to the collection of 

information unless it displays a currently valid OMB control 

number. 

Public reporting burden for this collection of information is estimated to average 5 minutes per 

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

maintaining data needed, and completing and reviewing the collection of information. This is a 

mandatory collection of information as required by 30 CFR Part 48.9 and 48.29. The information 

provides MSHA with a monitoring tool for determining compliance requirements. The Certification of 

Training provides a means for operators to record and certify mandatory training received by miners. 

Send comments regarding the collection of information, including suggestions for reducing this burden 

to the U.S. Department of Labor, MIne Safety and Health Administration, Office of Standards, 

Regulations and Variances, 201 12th Street South, Suite 401, Arlington, Virginia 22202-5452.

DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE
MSHA Form 5000-23 

May 2021 (revised)

Page 2 of 5

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).

Certificate of Training U.S. Department of Labor 

Mine Safety and Health Administration

Approved OMB Number 1219-0009, May 31, 2024

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 108 and 110, Public Law 91-173 as amended by Public Law 95-164. 

Issue Certificate immediately 

Upon Completion of Training

Serial Number (for operator's use)

1. Print Full Name of Person Trained (first, middle, last)

2. Check Type of Approved Training Received:

Annual Refresher Experienced Miner Hazard Training

New Task 

(Specify below)

New Miner Other (Specify)

Date Task Initials

Instr Studt

Date Task Initials

Instr

Studt

3. Check Type of Operation and Related Industry:

A. Surface Construction Underground Shaft & Slope

B. Coal Metal Nonmetal

4. Date Training Requirements Completed

Check if not completed 

and go to Item 5, below.

If completed, go to item 6, below.

5. Check Subjects Completed (Use only for partially completed training):

Introduction to Work Environment

Hazard Recognition

Emergency Medical Procedures

H&S Aspects of Tasks Assigned

Statutory Rights of Miners

Self-Rescue & Respiratory Devices

Transport & Communications Systems

Roof/Ground Control 

& Ventilation

Mine Map; Escapeways; 

Emergency Evacuation; 

Barricading 

Cleanup; Rock Dusting

Mandatory Health & 

Safety Standards

Authority & Responsibility 

of Supervisors & Miners 

Representatives

Health

Electrical Hazards

First Aid

Mine Gases

Explosives

Prevention of Accidents

Other (specify)

7. Mine Name, ID, and Location of Training (if institution, give name and address)

8. Date 

I verify that I have completed the above training 

(signature of person trained)

I certify that the above training has been completed 

(signature of person responsible for training)
MSHA Form 5000-23 

May 2021 (revised)

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Instructions for Completing a Mine Safety and Health 

Administration Certificate of Training Form (5000-23)

All part 48 training must be properly recorded on a Mine Safety and Health Administration (MSHA) 

Form 5000-23 (training certificate), or on an MSHA approved alternate form. For additional policy 

information on the 5000-23 form, you may refer to the MSHA Program Policy Manual. To review the 

applicable policy use this link. 

The current MSHA Form 5000-23 has an expiration date of May 31, 2024, however, previously issued 

forms with an earlier expiration date may still be used. The printed version comes with four copies. 

Listed below are notations, which appear on the bottom right-hand side of the form, showing the 

intended use of each copy: 

Copy 1 (white) - Employer's Personnel Record Copy 2 (pink) 

- Employee's Record Copy Copy 3 (yellow) 

- Employee's Separation Copy Copy 4 (green) 

- Recordkeeping 

The following is a description of how to complete each item of the 5000-23. 

ITEM DESCRIPTION

Serial Number 

(for operator's use)

This is an optional field which may 

be used to help track employees by 

an identification number. There is 

no Federal requirement to use this 

field.

Item 1. Print Full Name of Person 

Trained 

(first, middle, last)

Enter the person's name who has 

received the training. 

Item 2. Check Type of 

Approved Training Received

There are five boxes for the five types 

of training required. Check the 

appropriate box(es) to indicate what 

training was given. 

When New Task is checked, additional 

space is provided to record 1-8 task 

training events. This space is used to 

identify each task and to allow for the 

initials of the instructor(s) and the 

student (miner), as needed.
MSHA Form 5000-23 

May 2021 (revised)

Page 4 of 5

Item 3. Check Type of Operation 

and Related Industry

(1) Mark the box for the appropriate 

commodity: coal, metal or nonmetal. 

(2) Mark the box for the appropriate 

location: surface or underground. (3) 

Mark the appropriate box if the 

training is for construction or shaft 

and slope work. When completed the 

box should identify the type of 

mining, location and if construction or 

shaft and slope activities are 

involved.

Item 4. Date Training 

Requirements Completed

Depending on whether the training is 

complete or partial will determine how 

this item is completed. Only entering 

a date indicates that the training 

marked in item 2 is completed. 

Placing a check in the box to the right 

of the date entry, indicates that the 

training for the program(s) marked in 

item 2 is not complete. The appropriate 

boxes in item 5 must then be checked 

to indicate what subjects were 

completed. 

The following are some examples of 

partially completed training: (1) 

training for new miners given away 

from the mine site (which will then 

require site specific training at the 

mine site); (2) utilizing the 8 and 16 

hours of new miner training within 60-

day provision for new surface miners; 

and (3) providing partially completed 

annual refresher training.

Item 5. Check Subjects Completed 

(use only for partially completed training)

This is generally used for conducting 

annual refesher training in 

increments throughout an annual 

refresher cycle; or for new miner 

training which does not cover mine 

specific courses that are required to 

be covered at the mine site.

Item 6. Signature of 

person responsible for 

training

Upon completion of a MSHA 

approved training program, such as 

experienced miner, task, or annual 

refresher training, you must record 

and certify on the 5000-23 form that 

the miner has received the specified 

training.
MSHA Form 5000-23 

May 2021 (revised)

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The person signing the form in item 6 

is representing that the miner has 

received the indicated training. 

Anyone falsifying the 5000-23 form is 

criminally liable under section 110(a) 

and (f) of the Federal Mine Safety 

and Health Act. 

Generally, the person signing the 

form is the mine operator or a person 

acting on behalf of the operator. For 

example, a company safety official, a 

trainer employed or contracted by the 

operator, or a cooperative instructor 

(such as, a state grantee).

Item 7. Mine Name, ID, & Location 

of Training 

(if instruction, give name & address)

List the mine name, mine ID and 

location where training was 

conducted. If the training was 

conducted by a cooperative instructor 

or state grantee and a class 

participant is not employed at a 

particular mine, fill in the cooperative 

instructor's name or state name and 

address.

Item 8. Date and (signature of 

person trained)

The person trained has the option of 

signing and dating the form, 

acknowledging that the training 

indicated on the form was received. 

A copy of the 5000-23 form must be 

given to the miner upon completion 

of each MSHA approved training 

program, such as experienced miner, 

task, or annual refresher training.