Application Msha Instructor Form PDF Details

Mines Safety and Health Administration (MSHA) requires that all operators of mobile equipment complete an approved training course. The approved course must include a written test, and the operator must be able to demonstrate competence in operating mobile equipment. A training provider may offer a "train the trainer" program which allows instructors who satisfactorily complete the program to train other employees of the mine. This form is used by employers to apply for instructor status for their employees. The Mines Safety and Health Administration (MSHA) administers federal occupational safety and health standards in the mining industry. MSHA requires that all operators of mobile equipment complete an approved training course before they are allowed to operate mobile equipment at a mine site. The operator must also be able to pass

Form NameApplication Msha Instructor Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesapplication approved instructor, application msha approved search, application msha approved form, application for msha instructor

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30 CFR, Parts 48.3h (2), 48.23h (2), and 49.8d

NAME _____________________________ MIIN NUMBER: ________________________

EMPLOYER ________________________

MINE ID: ____________________

ADDRESS: _________________________

WORK PHONE: _______________

CITY: ____________________STATE ___

ZIP CODE: ___________________

*Please check the box next to the program areas for which you request approval*



New Miner Training




Experienced Miner Training




Annual Refresher Training





New Miner Training





Experienced Miner Training









Annual Refresher Training



Underground Coal


Surface Coal


Underground Metal


Surface Metal


Underground Nonmetal


Surface Nonmetal


Mining or Mining Related Job Experience

Job Title: Classification




Safety Meetings


Job (task) Training




Mining Training School




Other _________________


Mining or Mining Related Subjects Taught


Health and Safety Subjects Taught




New Miner Training, Annual Refresher , Other Courses or Mining, Safety, or Teaching Degrees Received

I certify that the above information is true and correct. False certification is punishable under Section 110(a) and (f) of the Federal Mine Safety and Health Act (Public Law 91-173 as amended by Public Law 95-164).

Signature _____________________________________________ Date _____________________

Instructions for completing

Application for MSHA Approved Instructor Form

-Basic contact information: PLEASE PRINT CLEARLY ON ENTIRE FORM

The first portion of this form is self explanatory. At this time MSHA is requiring you include your MSHA MIIN number, you can apply for this on the MSHA web site or by calling MSHA at 1-800-579-2647. MSHA will not process the application without it. The phone number you include should be one that is available to you

during the hours of 8 AM- 5PM M-F, this is the number that MSHA will contact you at if they have questions about your application.

-Please Check The Box Next To The Program Areas For Which You Seek Approval: You will have at least 3 check marks in this area but not more than 6, if you are seeking approval for Underground certification please note that you must demonstrate Underground experience in the sections to follow.

-Teaching or Instructing Experience Where you have Conducted Class:

This area would include ANY training that you have instructed in the following categories listed on the application.

-Mining or Mining Related Subjects Taught:

In this area you would include ALL experience where you have instructed to one or more individuals. Mining related includes anything that could be applied to the mining industry. Some examples would include: Annual Refresher Training, New Miner Training, First Aid/CPR, OSHA Courses, Construction Safety Courses, and/or Task Training.

-Health and Safety Subjects Taught:

This area would include any other Health and Safety courses you may have instructed including but not limited to: Homeland Security Safety, Concealed Weapon Safety, Defensive Driving, Workplace Safety, CPR, or anything else relating to Health and Safety.

-Mine and Mine Related Training You Have Received:

This area would include but not limited to; New Miner, Annual Refresher, Newly Hired Experience, First Aid/CPR, Task, Equipment, Dust, Noise, HAZCOM, or any other training you may have received that was either directly or indirectly correlated with mining. If you have less than one year mining experience you must list in detail what topics you received in your New Miner Training.


Don’t forget to sign your Certification/Application, and remember that by signing this form you give MSHA consent to verify any information that you have listed on the form. Any falsification of information can, and will be, dealt with accordingly.


You must include a detailed resume showing details for the information you provide on the Application/Certification. Your resume should include approximate dates, names, addresses and phone numbers for the locations and contact people for all the training given or received, and experience you listed on the form. Failure to provide this information will delay or may possibly get your application rejected by MSHA.

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If you want to complete this PDF document, be sure you type in the required details in every blank:

1. The application approved instructor will require particular details to be entered. Be sure that the next fields are completed:

Writing part 1 of msha ground testing procedure

2. Once the previous section is done, you have to put in the required particulars in Job Title Classification, Details, Years, TEACHING OR INSTRUCTING EXPERIENCE, Safety Meetings CollegeUniversity, years years years, Job task Training Mining Training, years years years, Mining or Mining Related Subjects, Years, Health and Safety Subjects Taught, and Years allowing you to proceed further.

Completing section 2 in msha ground testing procedure

Always be extremely careful while completing Health and Safety Subjects Taught and Details, as this is where many people make errors.

3. Within this stage, take a look at Dates New Miner Training Annual, MINE AND MINE RELATED TRAINING YOU, and I certify that the above. These have to be filled out with utmost accuracy.

Part no. 3 in filling out msha ground testing procedure

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