Fire Safety Survey Report Forms (CMS-2786)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-2786U Fire Safety Survey Report - ASC & ESRD Medicare	Form and Instruction	Modified	Available
Form CMS-2786Y FSES - Part III Chapter 7-101A - Board Care	Form	Modified	Available
Form CMS-2786X FSES - ICFs/MR Worksheet for Rating Residents	Form	Modified	Available
Form CMS-2786W FSES - ICFs/MR - Larger Facilities	Form	Modified	Available
Form CMS-2786V` FSES-ICFs/MR-Small Facilities	Form	Modified	Available
Form CMS-2786T FSES Worksheet	Form	Modified	Available
Form CMS-2786 M Fire Safety Survey Report	Form	Modified	Available
Form CMS-2786S Fire & Safety Survey Report	Form	Modified	Available
Form Fire & Safety Surv CMS-2786R	Form	Modified	Available
Brief description of changes to 2786U form.doc	Supplementary Document	Uploaded 2009-02-25	Available
CMS-2786 Supporting Statement.doc	Supporting Statement A	Uploaded 2009-03-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7898	Fire Safety Survey Report Forms (CMS-2786)	Form and Instruction	Modified	Fire Safety Survey Report - ASC & ESRD Medicare
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	FSES - Part III Chapter 7-101A - Board Care
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	FSES - ICFs/MR Worksheet for Rating Residents
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	FSES - ICFs/MR - Larger Facilities
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	FSES-ICFs/MR-Small Facilities
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	FSES Worksheet
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	Fire Safety Survey Report
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	Fire & Safety Survey Report
7898	Fire Safety Survey Report Forms (CMS-2786)	Form	Modified	CMS-2786R

ICR Details

OMB Control No: 0938-0242	ICR Reference No: 200904-0938-004
Status: Historical Active	Previous ICR Reference No: 200703-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Fire Safety Survey Report Forms (CMS-2786)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/24/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/02/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2012	36 Months From Approved	06/30/2010
Responses	27,900	0	27,900
Time Burden (Hours)	2,325	0	2,325
Cost Burden (Dollars)	0	0	0

---

Abstract: These forms are used by the State agencies to record data collected to determine compliance with individual conditions during fire safety surveys and report it to the Federal Government.

---

Authorizing Statute(s): US Code: 42 USC 416 Name of Law: 44
   US Code: 42 USC 482 Name of Law: 41
   US Code: 42 USC 483 Name of Law: 70
   US Code: 42 USC 460 Name of Law: 72
   US Code: 42 USC 483 Name of Law: 470
   US Code: 42 USC 485 Name of Law: 623
   US Code: 42 USC 418 Name of Law: 100
   Statute at Large: 18 Stat. 1861
   Statute at Large: 18 Stat. 1820
   Statute at Large: 18 Stat. 1819
   Statute at Large: 19 Stat. 1919
   Statute at Large: 19 Stat. 1905
   Statute at Large: 18 Stat. 1832
   Statute at Large: 18 Stat. 1881
   Statute at Large: 18 Stat. 1894
   Statute at Large: 11 Stat. 1102
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AG82	Final or interim final rulemaking	73 FR 20370	04/15/2008

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 67518	11/14/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 11732	03/19/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Fire Safety Survey Report Forms (CMS-2786)	CMS-2786W, CMS-2786X, CMS-2786Y, CMS-2786U, Fire & Safety Survey Report, CMS-2786S, CMS-2786 M, CMS-2786T, CMS-2786V`	CMS-2786R ,   Fire & Safety Survey Report ,   Fire Safety Survey Report ,   FSES Worksheet ,   FSES-ICFs/MR-Small Facilities ,   FSES - ICFs/MR - Larger Facilities ,   FSES - ICFs/MR Worksheet for Rating Residents ,   FSES - Part III Chapter 7-101A - Board Care ,   Fire Safety Survey Report - ASC & ESRD Medicare

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	27,900	27,900	0	0	0	0
Annual Time Burden (Hours)	2,325	2,325	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $206,767

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/02/2009

---