Representative of Miners Designation Form U.S. Department of Labor 

 Mine Safety and Health Administration 

Approved OMB Control Number 1219-0042, is approved for use through 12/31/2023 

data sources, gathering and maintaining the date need, and completing and reviewing the collection of information. Persons are not required to respond to this collection 

with 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 of Standards, Regulation and 

Instructions for this form contain further information on the need and use of this form. A false 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)). 

Variances, Mine Safety and Health Administration, 201 12th Street South, Suite 401, Arlington, VA 22202-5452. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. 

of information of unless it displays a current OMB Control Number. The DOL offers no pledge of confidentiality in association with these information collections unless 

Item 2 is checked and DOL will keep the miners' names and contact information confidential (Item 7) if Item 2 is checked. Section 103(f) and (g) of the Federal Mine Safety 

and Health Act, as amended, (30 U.S.C. § 813(f) and (g)) and 43 FR 29508, 29509. As a practical matter, the DOL would only release this information in accordance 

Item 1: Initial Filing Update Unknown 

Item 2: Confidential 

Item 3: Designation Type: Individual Organization 

Representative Name: Title: ___________________ 

Address:

City: ___________________________ State: Zip Code

Telephone ( ) Email:

Item 4: Mine Operator's or Contractor's Name

Mine Address __________________________________ 

Mine MSHA ID No.:

Item 5: Scope of Designation: The person or position named as the representative of miners is the 

 representative for all purposes of the Act.

 The representative’s authority is limited to: 101 (c)

 103 (c)

 Other 

Item 6: Additional or Alternate Representatives:

1. Name: ______________________________________ 

Address:

City: ___________________________ State: Zip Code

Telephone: ( ___ ) _____ __________ Email: ____________________________________________ 

2. Name: ______________________________________ 

Address:

City: ___________________________ State: Zip Code

Telephone: ( ___ ) _____ __________ Email: ____________________________________________ 

Item 7. Designated By: (Name of two or more miners who work at the mine) 

__________________________________ _______________________________ 1 – Name: 2 – Name: 

__________________________________ _______________________________ 1 – Telephone: 2 – Telephone: 

MSHA Form 2000-238, Aug. 2015 rev. (Mailing Address) 

I certify that I have been designated as representative by at least two miners who work at the mine. I certify that all information being filed is 

true and correct. A copy of this form has been delivered to the mine operator of the affected mine prior to or concurrently to the filing of this 

statement. 

Signed: _________________________________________________________ Date: ________________________________ 

Purpose: 30 CFR 40.3 authorizes a written declaration of any person or organization which represents two or more miners at a coal or other mine.

Public reporting burden for this collection of information estimated to average 45 minutes per response; including the time for reviewing instructions, searching existing 
Instructions for Completing MSHA Form 2000-238 

This form is a written declaration of any person or organization which represents two or more miners at a coal or other 

mine for the purposes of the Act. The use of this form is voluntary in complying with 30 C.F.R. § 40.3. 

Item 1. Type of filing. 

Check the box "initial filing" if a mine operator has not had a miners' representative designated under 

30 C.F.R. Part 40 or the appropriate information under Part 40 was not submitted to MSHA. For all other 

filings with MSHA concerning a miners' representative designation, check the "Updates" box. If the miners' 

representative is uncertain about the type of filing, check the box "Unknown." This box should be used 

sparingly. 

Item 2. Confidential Designation. 

This item is completed only if the two miners who are designating the individual or entity as their miners' 

representative want their identities to remain confidential, i.e., an anonymous designation. Check the box if 

the miners want a confidential designation. 

Item 3. Designation. (REQUIRED). 

This item must be completed. Provide the name and other information identified in Item 3 for the individual 

or the organization (and the title of the position of the representative in the organization) that the two miners 

have designated under Part 40. 

Item 4. Mine Operator's or Contractor's Name and ID. (REQUIRED). 

The name of the mine operator or contractor is required to identify the mine that the miners have designated 

this representative for the purposes provided in the Federal Mine Safety and Health Act of 1977 (Mine Act). 

The MSHA assigned Mine ID or Contractor ID number must be filled in to verify that MSHA has the correct 

mine for this representative. 

Item 5. Scope of Designation. 

Miners' representative may serve for all or selected purposes under the Mine Act. Check the appropriate 

box for the miners' representative designated in Item 3. If the section of the Mine Act is not identified, check 

the "other" box and fill in the information provided on the form. 

Item 6. Additional or Alternate Representatives. 

Check the box if you are providing any additional or alternate representatives. If you are providing more 

than two, you may print out this form and add as many representatives on a supplemental page and mail the 

form to the appropriate Coal or Metal and Nonmetal Safety and Health District Manager. 

Item 7. Designated By. (REQUIRED). 

Item 7 is required to be completed. It Item 2 is checked, then the information in Item 7 will be kept 

confidential. 

Privacy Act Statement 

30 C.F.R. § 40.3 authorizes the collection of this information. This information will be used by MSHA inspectors to 

contact the miners' representative once the inspector is at the mine before conducting an inspection. This information 

also permits MSHA to verify that miners' representative was designated by two miners who work at the mine. This is 

very important for confidential or anonymous designations. Section 103(f) and (g) of the Mine Act, (30 U.S.C. § 813(f) 

and (g)) and 43 FR 29508, 29509 submission of the items identified in the instructions as required is mandatory and 

failure to submit the required information may delay MSHA ability to verify the designation of the miners' representative 

and delay the miners' representative participating in inspection activities at the mine.