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["ENTER UNIT NAME HERE"]
[]
["CMAA/TIME SURVEY TRAINING IN-HOUSE"]
["Fiscal Year 2018-19"]
[]
["IN-HOUSE ATTENDANCE/SIGN-IN SHEET"]
["Date","Location","Last Name, First Name","Staff Classification Per Claim Plan","Signature (must be in BLUE ink)"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[null,null,null,null,"Sign in blue ink HERE"]
[]
["TRAINER'S CERTIFICATION:"]
["I CERTIFY THAT THE PARTICIPANTS ABOVE HAVE ATTENDED THE CMAA TIME SURVEY TRAINING WEBINAR IN COMPLIANCE TO THE STATE/FEDERAL  RULES AND REGULATIONS."]
["Signature of Trainer (in blue ink)"]
["Name of Trainer (printed):"]
["Classification of Trainer:"]
["Trainer's date of Training:"]
[]
["NOTE:  PLEASE KEEP A COPY IN YOUR AUDIT FILE.   "]
[]
[]
["SUBMIT/MAIL THE ORIGINAL DOCUMENT TO:"]
["JESSICA VICTORINO"]
["MEDI-CAL ADMINISTRATIVE ACTIVITIES"]
["HEALTH SERVICES AGENCY "]
["1080 EMELINE AVENUE, BLDG. D, BASEMENT"]
["SANTA CRUZ, CA 95060"]