Information Collection

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

IC 187984 under ICR 201402-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form
CMS-10036.IRF-PAI pressure ulcer instructions for PRA.docx	Instruction
CMS-10036 IRF PAI Instrument CMS-10036.Draft IRF-PAI Instrument.pdf	Form
CMS-10036_IRF-PAI_Revisions Crosswalk.docx CMS-10036_IRF-PAI_Revisions Crosswalk	IC Document

IC Title:

Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 412 Subpart P

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	CMS-10036	IRF PAI Instrument	CMS-10036.Draft IRF-PAI Instrument.pdf		Yes	No	Fillable Fileable
Instruction			CMS-10036.IRF-PAI pressure ulcer instructions for PRA.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: : Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) System of Records, System No. 09-70-1518

FR Citation: 66 FR 56681

Number of Respondents: 9

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-3,330	3,330
Annual IC Time Burden (Hours)	-2,831	2,831
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10036_IRF-PAI_Revisions Crosswalk	CMS-10036_IRF-PAI_Revisions Crosswalk.docx	06/01/2011

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