Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 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⚠️ Notice: This information collection may be referencing outdated material.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	Form and Instruction
CMS-10036 Voluntary/Mandatory Items IRF-PAI Voluntary Mandatory Chart 02-20-2014.doc	Form and Instruction
CMS-10036 IRF-PAI instrument IRF-PAI_Oct_2014_v4.pdf	Form and Instruction
CMS Crosswalk- IRF-PAI 2014 Admission v2.doc Crosswalk - Admissions	IC Document
CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc Crosswalk - Discharge	IC Document
Pt Influenza Measure. Burden Calculation. 03.21.13.docx Infulenza Burden	IC Document
PU Burden Calculation. 03.26.13.docx Pressure Ulcer Burden	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:

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	IRF-PAI Voluntary Mandatory Chart 02-20-2014.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10036	IRF-PAI instrument	IRF-PAI_Oct_2014_v4.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Inpatient Rehabilitation Facility - Patient Assessment Instrument

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
	Approved	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
Crosswalk - Admissions	CMS Crosswalk- IRF-PAI 2014 Admission v2.doc	02/28/2014
Crosswalk - Discharge	CMS Crosswalk- IRF-PAI 2014 Discharge v2.doc	02/28/2014
Infulenza Burden	Pt Influenza Measure. Burden Calculation. 03.21.13.docx	02/28/2014
Pressure Ulcer Burden	PU Burden Calculation. 03.26.13.docx	02/28/2014

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