Information Collection

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

IC 187983 under ICR 200902-0938-004 · OMB 0938-0842.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0842 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10036 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form
irfpai-manual040104.pdf	Instruction
CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment I CMS-10036.pdf	Form

IC Title:

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 412 Subpart P

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10036	Inpatient Rehabilitation Facility - Patient Assessment Instrument	CMS-10036.pdf		Yes	Yes	Paper Only
Instruction			irfpai-manual040104.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: : Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) System of Records, System No. 09-70-1518

FR Citation: 66 FR 56681

Number of Respondents: 160

Number of Respondents for Small Entity: 31

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	52,800	52,800
Annual IC Time Burden (Hours)	44,880	44,880
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.