Information Collection

Inpatient Rehabilitation Facility-Patient Assessment Instrument

IC 207222 under ICR 201306-0938-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Version 1.2 (Proposed DRAFT Effective October 1, 2014) Assessment Quality Indicator Items- Sect 3004 IRF Quality Reporting Program Inpatient Rehabilitation Facility-Patient Assessment Instrument	Form and Instruction
Form CMS-10036 IRF-PAI Instrument Inpatient Rehabilitation Facility-Patient Assessment Instrument	Form and Instruction
CMS-10036 Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Ver IRF-PAI-VolMandatChart_v3_508.pdf	Form and Instruction
CMS-10036 IRF-PAI Instrument 508c IRF-PAI 2014.pdf	Form and Instruction
PU Burden Calculation. 03.26.13.docx Pressure Ulcer Burden Calculation	IC Document
CMS Crosswalk- IRF-PAI 2014 Admission v2.doc Crosswalk - IRF PAI 2014 Admission	IC Document
CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc Crosswalk - IRF-PAI 2014 Dischare	IC Document
Pt Influenza Measire. Burden Calculation. 03.21.13.docx Influenza Burden Calculation	IC Document

IC Title:

Inpatient Rehabilitation Facility-Patient Assessment Instrument

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 Subpart P (To search for a specific CFR, visit the Code of Federal Regulations.)

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-10036	Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Version 1.2 (Proposed DRAFT Effective October 1, 2014) Assessment Quality Indicator Items- Sect 3004 IRF Quality Reporting Program	IRF-PAI-VolMandatChart_v3_508.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10036	IRF-PAI Instrument	508c IRF-PAI 2014.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Inpatient Rehabilitation Facilities (IRF) Patient Assessment Instrument (IRF-PAI),''

FR Citation: 71 FR 67143

Number of Respondents: 1,161

Number of Respondents for Small Entity: 194

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	359,000	359,000
Annual IC Time Burden (Hours)	197,080	197,080
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pressure Ulcer Burden Calculation	PU Burden Calculation. 03.26.13.docx	06/04/2013
Crosswalk - IRF PAI 2014 Admission	CMS Crosswalk- IRF-PAI 2014 Admission v2.doc	06/04/2013
Crosswalk - IRF-PAI 2014 Dischare	CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc	06/04/2013
Influenza Burden Calculation	Pt Influenza Measire. Burden Calculation. 03.21.13.docx	06/05/2013

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