Form 2000-222 SCSR Inventory and Report

INSTRUCTIONS: This form is for Operators’ use in providing MSHA with complete SCSR inventories as well as in reporting problems with SCSRs. Operators may attach continuation sheets to this form provided all required SCSR information is included. Enter date information is being reported, MSHA- issued mine ID, name mine is operating under, company name, address of mine, contact name and telephone number. Select the manufacturer/model, enter date of manufacture, serial number and report date. If “Other MSHA-approved SCSR ____” is selected, write in the manufacturer/model. The use of this form is voluntary in complying with 75.1714-8.

A false statement or representation is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act, as amended (30 U.S.C. § 820(a) and (f)).

Report Date:____________________ E-mail:____________________

Mine ID: __________________ Mine Name: ______________________________________

(MSHA Mine ID)

Company Name:__________________________ Address: __________________________________________

(Street, P.O.)

_________________________________________________

City State Zip

Contact name: __________________________ Telephone:____________

Check all that apply Create list below or attach to this form

Manufacturer/Model Date of Manufacture Serial Number In/Out Reason

 CSE SR-100 _________________ ____________   ________

 OCENCO EBA 6.5 _________________ ____________   ________

 OCENCO M20 _________________ ____________   ________

 DRAEGER OXY-K Plus ________________ ____________   ________

 DRAEGER OXY-K Plus S _________________ ____________   ________

 MSA LIFE-SAVER 60 _________________ ____________   ________

 Other MSHA-approved SCSR_______ _________________ ____________   ________

If reporting an SCSR out of inventory, identify the SCSR and enter reason number above:

1) Out for Refurbishment 2) Damaged/Not Repairable 3) Out of Date 4) Missing

5) Transferred 6) Used/Activated 7) Data Entry Error

Send this form to: Mine Safety and Health Administration

Technical Support

Pittsburgh Safety and Health Technology Center

Attn: SCSR Coordinator

Cochrans Mill Road
    P.O. Box 18233
    Pittsburgh, Pennsylvania 15236

Purpose: 30 CFR 75.1714-8 authorizes the collection of this information. MSHA maintains an inventory of all reported SCSR information to assure the effectiveness of evacuation plans and emergency evacuations. In addition, such an inventory will assist in targeting SCSR recalls to specific mines. The use of this form will facilitate SCSR inventory information transfer from mine operators to MSHA. MSHA may not sponsor or endorse products.

Burden Statement: Public reporting burden for this collection of information is estimated from 3 hours to 19 hours depending on the size of the mine per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection information. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. The DOL offers no pledge of confidentiality in association with these information collections. As a practical matter, the DOL would only release this information in accordance with the provisions of the Freedom of Information Act (5 U.S.C. § 552); the Privacy Act (5 U.S.C. § 552a); and attendant regulations, 29 C.F.R. parts 70 and 71. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Records Management Branch, Mine Safety and Health Administration, 1100 Wilson Boulevard, Arlington, VA 22209-3939. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

MSHA Form 2000-222 (Rev. March 2010) (Previous versions are usable.)

MSHA Form 2000-222 (Rev March 2010) – Previous versions are usable

SCSR Inventory and Report U.S. Department of Labor

OMB Control No. 1219-0141 (Expires 3/31/2010) Mine Safety and Health Administration