MSHA Form 5000-23, May 13 (revised): Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering the full name of the person trained in the designated field. Ensure accuracy as this is a critical component of the certification.
Select the type of approved training received by checking the appropriate box. Options include Annual, Experienced Miner, Refresher, New Task, and New Miner. If applicable, specify any new tasks below.
Indicate the type of operation and related industry by checking one or more boxes that apply, such as Surface, Underground, Coal, or Metal.
Fill in the date when training requirements were completed. If not completed, check the corresponding box and proceed to item 5.
If training is partially completed, check all subjects that have been completed from the provided list.
Ensure that both signatures are obtained: one from the person responsible for training and another from the person trained.
Finally, enter the mine name, ID, and location of training before saving your document.

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