Information Collection

Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)

IC 8848 under ICR 201206-0938-010 · OMB 0938-0986.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0986 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-437A Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)	Form and Instruction
CMS-437A Rehabilitiation Unit Criteria Worksheet CMS437A.pdf	Form and Instruction
CMS-437B Rehabilitation Hospital Criteria Worksheet CMS437B.pdf	Form and Instruction
Crosswalk for Changes to Rehabilitation Hospital Worksheet and Rehabilitation Unit Worksheet 6-24-12.docx Crosswalk for Changes to Rehabilitation Hospital Worksheet and Rehabilitation Unit Worksheet 6-24-12	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet and Supporting Regulations at 42 CFR 412.20-412.30 (CMS-437A&B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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 and Instruction	CMS-437A	Rehabilitiation Unit Criteria Worksheet	CMS437A.pdf		Yes	No	Printable Only
Form and Instruction	CMS-437B	Rehabilitation Hospital Criteria Worksheet	CMS437B.pdf		Yes	No	Printable Only

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: 1,164

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,164	-63	1,227
Annual IC Time Burden (Hours)	291	-16	307
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk for Changes to Rehabilitation Hospital Worksheet and Rehabilitation Unit Worksheet 6-24-12	Crosswalk for Changes to Rehabilitation Hospital Worksheet and Rehabilitation Unit Worksheet 6-24-12.docx	06/30/2012

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