Inpatient Rehabilitation Facility - Patient Assessment Instrument

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

⚠️ Notice: This information collection may be referencing outdated material.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

Information Collection (IC) Details

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:

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 %

	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

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.