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Information Collection

155.225(b)(1)(i) (certificate issuance)

IC 207938 under ICR 202210-0938-013 · OMB 0938-1205.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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155.225(b)(1)(i) (certificate issuance)
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
45 CFR 155.225(b)(1)(i)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10494 Training Certificate CMS-10494 - Appendix E_ SampleTraining Completion Certificate (1).docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Training Certificate (English) CMS-10494 - Appendix H_Sample Certification Certificate English.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10494 Sample Certification Certificate (Spanish) CMS-10494 - Appendix I_Sample Certification Certificate Spanish.docx Yes Yes Fillable Fileable

Health Health Care Services

 

5,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30,000 0 0 0 0 30,000
Annual IC Time Burden (Hours) 480 0 0 0 0 480
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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