CMS-10717 Attendance Log for Meetings/Webinars/Conferences

Attendance Log for Meetings/Webinars/Conferences
Conference/Interview Purpose:
Date and Time:
Name

Title

Department/Entity

Upload to HPMS Audit Module as File Type “Supplemental File” in the respective Level
Association (“Audit” or in a specific program area). File must be named “Attendance_LogCCYY_MM_DD”
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1395 (Expires
05/31/2024). This is a mandatory information collection. The time required to complete this information collection is estimated
to average 701 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications,
claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office.
Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB
control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact [email protected].
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OMB Approval 0938-1395 (Expires 05/31/2024)