Information Collection

Fire Safety Survey Report Forms (CMS-2786)

IC 7898 under ICR 200703-0938-010 · OMB 0938-0242.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0242 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Fire & Safety Surv Fire Safety Survey Report Forms (CMS-2786)	Form
Fire & Safety Surv CMS-2786R CMS-2786R.pdf	Form
CMS-2786S Fire & Safety Survey Report CMS-2786S.pdf	Form
CMS-2786 M Fire Safety Survey Report CMS-2786M.pdf	Form
CMS-2786T FSES Worksheet CMS-2786T.pdf	Form
CMS-2786U ASCs survey CMS-2786U.pdf	Form
CMS-2786V` FSES-ICFs/MR-Small Facilities CMS-2786V.pdf	Form
CMS-2786W FSES - ICFs/MR - Larger Facilities CMS-2786W.pdf	Form
CMS-2786X FSES - ICFs/MR Worksheet for Rating Residents CMS-2786X.pdf	Form
CMS-2786Y FSES - Part III Chapter 7-101A - Board Care CMS-2786Y.pdf	Form

IC Title:

Fire Safety Survey Report Forms (CMS-2786)

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.744 42 CFR 418.100 42 CFR 485.623 42 CFR 482.41 42 CFR 460.72 42 CFR 483.70 42 CFR 483.470 42 CFR 416.44

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Fire & Safety Survey Report	CMS-2786R	CMS-2786R.pdf	No	No	Paper Only
Form	CMS-2786S	Fire & Safety Survey Report	CMS-2786S.pdf	No	No	Paper Only
Form	CMS-2786 M	Fire Safety Survey Report	CMS-2786M.pdf	No	No	Paper Only
Form	CMS-2786T	FSES Worksheet	CMS-2786T.pdf	No	No	Paper Only
Form	CMS-2786U	ASCs survey	CMS-2786U.pdf	No	No	Paper Only
Form	CMS-2786V`	FSES-ICFs/MR-Small Facilities	CMS-2786V.pdf	No	No	Paper Only
Form	CMS-2786W	FSES - ICFs/MR - Larger Facilities	CMS-2786W.pdf	No	No	Paper Only
Form	CMS-2786X	FSES - ICFs/MR Worksheet for Rating Residents	CMS-2786X.pdf	No	No	Paper Only
Form	CMS-2786Y	FSES - Part III Chapter 7-101A - Board Care	CMS-2786Y.pdf	No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27,900

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	27,900	27,900
Annual IC Time Burden (Hours)	2,325	2,325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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