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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10036 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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.