Information Collection

Fire Safety Survey Report Forms (CMS-2786)

IC 7898 under ICR 200904-0938-004 · OMB 0938-0242.

Documents and Forms

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-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
CMS-2786U Fire Safety Survey Report - ASC & ESRD Medicare CMS-2786U revised 10-2008.pdf Form and Instruction
Brief description of changes to 2786U form.doc Brief description of changes to 2786U form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Fire Safety Survey Report Forms (CMS-2786)	Agency IC Tracking Number:

Is this a Common Form? No		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:

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-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
Form and Instruction	CMS-2786U	Fire Safety Survey Report - ASC & ESRD Medicare	CMS-2786U revised 10-2008.pdf	Yes	Yes	Fillable Fileable

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 %

	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

Title	Document	Date Uploaded
Brief description of changes to 2786U form	Brief description of changes to 2786U form.doc	02/25/2009

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