Underground mine operators must keep at least two mine rescue teams under 30 CFR Part 49, and each team member needs a physician's certificate of physical fitness for strenuous rescue and recovery work. MSHA Form 5000-3 is that certificate, completed after the member's examination and renewed every year.
The examining physician completes and signs the form for each member of a mine rescue team; it is a physician's certification of physical qualification rather than a patient questionnaire.
Download the current version from the source each time; forms change without notice.
Certificate of Physical Qualification for Mine Rescue Work
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Every year. Each mine rescue team member must be examined by a physician annually, and the first exam must take place within 60 days before the member's scheduled initial training. A new signed certificate is completed after each examination and kept on file at the mine rescue station.
No. The certificates are kept on file at the mine rescue station for one year. MSHA's form page specifically says not to send the completed form to the address in its burden statement. The mine operator keeps them available for review.