Form 5000-23 at a glance
What it is: Form 5000-23 is the Mine Safety and Health Administration Certificate of Training.
Who signs: 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).
A filled-in Form 5000-23 example: a trainer certifies an annual refresher
How to fill out Form 5000-23, box by box
Serial Number and Print Full Name of Person Trained
Serial Number (for operator's use) 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.
Check Type of Approved Training Received
Item 2. Check Type of Approved Training Received Check the appropriate box(es) to indicate what training was given.
New Task training events
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.
Check Type of Operation and Related Industry
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.
Date Training Requirements Completed
Item 4. Date Training Requirements 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.
Check if not completed and go to Item 5, below. If completed, go to item 6, below.
Check Subjects Completed
Item 5. Check Subjects Completed (use only for partially completed training) This is generally used for conducting annual refresher 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.
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.
Signature of person responsible for training
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. The person signing the form in item 6 is representing that the miner has received the indicated training.
Mine Name, ID, and Location of Training
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.
Date and signature of person trained
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.
Common questions about Form 5000-23
What is a 5000-23 form?
Form 5000-23 is the Mine Safety and Health Administration Certificate of Training. 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.
Is there a penalty?
Anyone falsifying the 5000-23 form is criminally liable under section 110(a) and (f) of the Federal Mine Safety and Health Act.
Sources
[1] Form 5000-23 (Rev. February 2025), Certificate of Training, Mine Safety and Health Administration, U.S. Department of Labor (the Official source link on this page).