Information Collection

155.225(d)(1) - Training certificate proof

IC 208216 under ICR 201703-0938-005 · OMB 0938-1205.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1205 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10494 155.225(d)(1) - Training certificate proof	Form and Instruction
CMS-10494 Registration CMS-10494-F2-APPENDIX A.docx	Form and Instruction
CMS-2334-F2-APPENDIX B.PDF Data Elements	IC Document

IC Title:

155.225(d)(1) - Training certificate proof

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.225(d)(1)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10494	Registration	CMS-10494-F2-APPENDIX A.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Elements	CMS-2334-F2-APPENDIX B.PDF	08/14/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.