Information Collection

155.225(d)(1) - Training certificate proof

IC 208216 under ICR 202210-0938-013 · OMB 0938-1205.

Documents and Forms

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-10494 Registration CMS-10494-F2-APPENDIX A.docx Form and Instruction
CMS-2334-F2-APPENDIX B.PDF Data Elements IC Document
CMS-2334-F2-APPENDIX B.PDF Data Elements IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	155.225(d)(1) - Training certificate proof	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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

Information Collection 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 %

	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

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.