Information Collection

Fire Safety Survey Report Forms (CMS-2786)

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

Documents and Forms

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

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Fire & Safety Survey Report	No	No	Paper Only
Form	CMS-2786S	No	No	Paper Only
Form	CMS-2786 M	No	No	Paper Only
Form	CMS-2786T	No	No	Paper Only
Form	CMS-2786V`	No	No	Paper Only
Form	CMS-2786W	No	No	Paper Only
Form	CMS-2786X	No	No	Paper Only
Form	CMS-2786Y	No	No	Paper Only
Form and Instruction	CMS-2786U	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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
Brief description of changes to 2786U form		02/25/2009

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

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