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Ky.gov An Official Website of the Commonwealth of Kentucky

Energy and Environment Cabinet

Certifications and Forms

Division of Mine Safety
Certification Forms

Click on the links below to access the documents you need.  Make sure to follow the directions on completing each document accurately:   

Accident Reporting Form - EB-83 Initial Accident Report Form

Affidavit - Surface Mine Foreman

Affidavit - Surface Mine Instructor

Affidavit - Underground Mine Foreman

Affidavit - Underground Mine Instructor

Affidavit - Underground Mine Safety Analyst Affidavit/Inspector

Affidavit - Hoist Engineer

Affidavit - Blaster Solid or Conventional

Affidavit - Electrical Experience

Certification - Electrical Examinations

Certification - MSHA Electrical Experience

Application - Assistant Mine Foreman to First Class Mine Foreman (Surface and Underground)

Electrical Instructor Certification Instructions

Electrical Instructor data sheet (Page 1)

Electrical Instructor data sheet (Page 2)

MSHA Electrical Qualifications

MET Initial 40-hour Course EF-18

Application for MET Certification EF-17: Certified EMT or certified EMT instructors who are exempted from challenging the MET examination

MET Retraining form EF-16

Miner Certification Application EG-47

Reinstatement Certification Application EG-44

Reciprocity Certification Application

MSHA Form 5000-23

Duplicate Card and Certification Request: Mine foreman, instructor (underground, surface and electrical), mine inspector and surface mine safety analyst 

Request for Card: Surface and Underground Miner, MET Instructor