CMS-10243 Functional Assessment Standardized Items (FASI)

Identifier (Assessor ID# / Recipient #) ___________

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1037. The time required to complete this information collection is estimated to average 30 minutes per response. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

 By checking this box, I certify that:
• I reviewed the consent form (and assent form when required) with the person and/or their Legally
Authorized Representative (LAR) and gave them the opportunity to ask questions,
• the person was cognitively competent to provide informed consent (if the person does not have an
LAR),
• or the person, or their LAR, provided informed consent by signing the form (and the person gave assent
when required),
• I have provided the person, or their LAR, with a signed copy of the consent (or assent form when
required), and
• I have retained another copy of the signed consent (and assent form when required) that I have securely
stored at my assessment entity.
I further certify, to the best of my knowledge, the information I have recorded in this assessment:
• was collected only after the person, or their LAR, provided informed consent/assent,
• was collected in accordance with the guidelines provided by CMS for participation in this TEFT FASI
Testing project,
• is an accurate and truthful reflection of assessment information for this person, and
• was entered accurately.

CMS-10243
OMB 0938-1037
Expiration Date: TBD

Identifier (Assessor ID# / Recipient #) ___________

Testing Experience and Functional Tools (TEFT)
Functional Assessment Standardized Items (FASI)
Please Complete All Items on Each Page
SECTION A

Identification Information
1. Recipient Study ID Number
State ID and observation number
2. Assessor ID Number
Assessor assigned number

1

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Self-Care
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s self-care performance was unchanged during the past month, column B should be coded the same as
column A. If the activity was not attempted, code the reason.
Please complete the Self-Care Priorities section at the bottom of this page.
CODING:
Safety and Quality of Performance – If
helper assistance is required because person’s
performance is unsafe or of poor quality score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent – Person completes the
activity by him/herself with no assistance
from a helper.
05. Setup or cleanup assistance – Helper
SETS UP or CLEANS UP; person
completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance –
Helper provides VERBAL CUES or
TOUCHING/STEADYING assistance as
person completes activity. Assistance
may be provided throughout the activity
or intermittently.
03. Partial/moderate assistance – Helper
does LESS THAN HALF the effort.
Helper lifts, holds or supports trunk or
limbs, but provides less than half the
effort.
02. Substantial/maximal assistance –
Helper does MORE THAN HALF the
effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the
effort. Person does none of the effort to
complete the activity. Or, the assistance
of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable – Person does not usually
do this activity.
88. Not attempted due to short-term
medical condition or safety concerns.

Performance Level
Enter Codes in Boxes
B
A
Usual

Most
Dependent

6a. Eating: The ability to use suitable
utensils to bring food to the mouth and
swallow food once the meal is presented
on a table/tray. Includes modified food
consistency.
6b. Oral hygiene: The ability to use suitable
items to clean teeth.
[Dentures (if applicable): The ability to
remove and replace dentures from and
to the mouth, and manage equipment
for soaking and rinsing them.]
6c. Toileting hygiene: The ability to
maintain perineal/feminine hygiene,
adjust clothes before and after using the
toilet, commode, bedpan or urinal. If
managing an ostomy, include wiping the
opening but not managing equipment.
6d. Wash upper body: The ability to wash,
rinse, and dry the face, hands, chest, and
arms while sitting in a chair or bed.
6e. Shower/bathe self: The ability to bathe
self in shower or tub, including washing,
rinsing, and drying self. Does not include
transferring in/out of tub/shower.
6f. Upper body dressing: The ability to put
on and remove shirt or pajama top;
includes buttoning, if applicable.
6g. Lower body dressing: The ability to
dress and undress below the waist,
including fasteners; does not include
footwear.
6h. Putting on/taking off footwear: The
ability to put on and take off socks and
shoes or other footwear that is
appropriate for safe mobility.

Self-Care Priorities: Please indicate your top two priorities in the area of self-care for the next six months.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________

2

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Mobility (Bed mobility and transfers)
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s transfer/bed mobility performance was unchanged during the past month, column B should be coded the
same as column A. If the activity was not attempted, code the reason.
CODING:
Safety and Quality of Performance – If
helper assistance is required because person’s
performance is unsafe or of poor quality score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent – Person completes the
activity by him/herself with no assistance
from a helper.
05. Setup or cleanup assistance – Helper
SETS UP or CLEANS UP; person
completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance –
Helper provides VERBAL CUES or
TOUCHING/STEADYING assistance as
person completes activity. Assistance
may be provided throughout the activity
or intermittently.
03. Partial/moderate assistance – Helper
does LESS THAN HALF the effort.
Helper lifts, holds or supports trunk or
limbs, but provides less than half the
effort.
02. Substantial/maximal assistance –
Helper does MORE THAN HALF the
effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the
effort. Person does none of the effort to
complete the activity. Or, the assistance
of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused
09. Not applicable – Person does not usually
do this activity
88. Not attempted due to short term
medical condition or safety concerns

Performance Level
Enter Codes in Boxes
B
A
Usual

Most
Dependent

7a. Roll left and right: The ability to roll
from lying on back to left and right side,
and return to lying on back.
7b. Sit to lying: The ability to move from
sitting on side of bed to lying flat on the
bed.
7c. Lying to sitting on side of bed: The
ability to safely move from lying on the
back to sitting on the side of the bed
with feet flat on the floor, and with no
back support.
7d. Sit to stand: The ability to safely come
to a standing position from sitting in a
chair or on the side of the bed.
7e. Chair/bed-to-chair transfer: The ability
to safely transfer to and from a bed to a
chair (or wheelchair).
7f. Toilet transfer: The ability to safely get
on and off a toilet or commode.

7g. Car transfer: The ability to transfer in
and out of a car or van on the passenger
side. Does not include the ability to
open/close door or fasten seat belt.

3

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Mobility (Ambulation)
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s ambulation mobility performance was unchanged during the past month, column B should be coded the
same as column A. If the activity was not attempted, code the reason.
CODING:
Safety and Quality of Performance – If
helper assistance is required because person’s
performance is unsafe or of poor quality score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent – Person completes the
activity by him/herself with no assistance
from a helper.
05. Setup or cleanup assistance – Helper
SETS UP or CLEANS UP; person
completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance –
Helper provides VERBAL CUES or
TOUCHING/STEADYING assistance as
person completes activity. Assistance
may be provided throughout the activity
or intermittently.
03. Partial/moderate assistance – Helper
does LESS THAN HALF the effort.
Helper lifts, holds or supports trunk or
limbs, but provides less than half the
effort.
02. Substantial/maximal assistance –
Helper does MORE THAN HALF the
effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the
effort. Person does none of the effort to
complete the activity. Or, the assistance
of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable – Person does not usually
do this activity.
88. Not attempted due to short-term
medical condition or safety concerns.

8. Does the person walk?
0. Yes – Continue to question 8a.
1. No, but walking is indicated in the future – skip to
question 9.
2. No, and walking is not indicated – skip to question 9.
Performance Level
Enter Codes in Boxes
B
A
Usual

Most
Dependent

8a. Walks 10 feet: Once standing, the
ability to walk at least 10 feet in a room,
corridor or similar space.
8b. Walks 50 feet with two turns: Once
standing, the ability to walk at least 50
feet and make two turns.
8c. Walks 150 feet: Once standing, the
ability to walk at least 150 feet in a
corridor or similar space.
8d. Walks 10 feet on uneven surfaces: The
ability to walk 10 feet on uneven or
sloping surfaces, such as grass or gravel.
8e. 1 step (curb): The ability to step over a
curb or up and down one step.
8f. 4 steps: The ability to go up and down
four steps with or without a rail.
8g. 12 steps: The ability to go up and down
12 steps with or without a rail.
8h. Walks indoors: from room to room,
around furniture and other obstacles.
8i. Carries something in both hands:
While walking indoors e.g. several
dishes, light laundry basket, tray with
food.
8j. Picking up object: The ability to
bend/stoop from a standing position to
pick up a small object, such as a spoon,
from the floor.
8k. Walks for 15 minutes: without stopping
or resting (e.g., department store,
supermarket.)
8l. Walks across a street: crosses street
before light turns red.

4

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Mobility (Wheelchair)
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s wheelchair mobility performance was unchanged during the past month, column B should be coded the
same as column A. If the activity was not attempted, code the reason.
Please complete the Mobility Priorities section at the bottom of this page.
9. Does the person use a manual wheelchair?
CODING:
0. No – Skip to question 10.
1. Yes – Continue to question 9a.
Safety and Quality of Performance – If
Manual Wheelchair
helper assistance is required because
Performance Level
person’s performance is unsafe or of poor
Enter Codes in Boxes
quality score according to amount of
B
assistance provided.
A
Most
Activities may be completed with or without
Usual
Dependent
assistive devices.
9a. Wheels 50 feet with two turns: Once
seated in wheelchair/scooter, the ability
06. Independent – Person completes the
to wheel at least 50 feet and make two
activity by him/herself with no
turns.
assistance from a helper.
9b.Wheels
150 feet: Once seated in
05. Setup or cleanup assistance – Helper
wheelchair/
scooter, the ability to wheel
SETS UP or CLEANS UP; person
at least 150 feet in a corridor or similar
completes activity. Helper assists only
space.
prior to or following the activity.
9c.
Wheels
for 15 minutes: without
04. Supervision or touching assistance –
stopping or resting (e.g., department
Helper provides VERBAL CUES or
store, supermarket.)
TOUCHING/STEADYING assistance as
9d.
Wheels across a street: crosses street
person completes activity. Assistance
before light turns red.
may be provided throughout the activity
or intermittently.
10. Does the person use a motorized wheelchair/scooter?
03. Partial/moderate assistance – Helper
0. No – Skip to question 11a.
does LESS THAN HALF the effort.
1. Yes – Continue to question 10a.
Helper lifts, holds or supports trunk or
Motorized Wheelchair/Scooter
limbs, but provides less than half the
Performance Level
effort.
Enter Codes in Boxes
02. Substantial/maximal assistance –
B
A
Helper does MORE THAN HALF the
Most
Usual
Dependent
effort. Helper lifts or holds trunk or
10a. Wheels 50 feet with two turns: Once
limbs and provides more than half the
seated in wheelchair/scooter, the
effort.
ability to wheel at least 50 feet and
01. Dependent – Helper does ALL of the
make two turns.
effort. Person does none of the effort to
10b. Wheels 150 feet: Once seated in
complete the activity. Or, the assistance
wheelchair/ scooter, the ability to
of 2 or more helpers is required for the
wheel at least 150 feet in a corridor or
person to complete the activity.
similar space.
10c. Wheels for 15 minutes: without
If activity was not attempted, code reason:
stopping or resting (e.g., department
07. Person refused.
store, supermarket.)
09. Not applicable – Person does not
usually do this activity.
88. Not attempted due to short-term
10d. Wheels across a street: crosses street
medical condition or safety concerns.
before light turns red.
Mobility Priorities: Please indicate your top two priorities in the area of mobility for the next six months.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________

5

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Instrumental Activities of Daily Living
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s IADL performance was unchanged during the past month, column B should be coded the same as column
A. If the activity was not attempted, code the reason.
CODING:
Safety and Quality of Performance – If
helper assistance is required because person’s
performance is unsafe or of poor quality score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent – Person completes the
activity by him/herself with no assistance
from a helper.
05. Setup or cleanup assistance – Helper
SETS UP or CLEANS UP; person
completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance –
Helper provides VERBAL CUES or
TOUCHING/STEADYING assistance as
person completes activity. Assistance
may be provided throughout the activity
or intermittently.
03. Partial/moderate assistance – Helper
does LESS THAN HALF the effort.
Helper lifts, holds or supports trunk or
limbs, but provides less than half the
effort.
02. Substantial/maximal assistance –
Helper does MORE THAN HALF the
effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the
effort. Person does none of the effort to
complete the activity. Or, the assistance
of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable – Person does not usually
do this activity.
88. Not attempted due to short-term
medical condition or safety concerns.

Performance Level
Enter Codes in Boxes
B
A
Usual

Most
Dependent

11a. Makes a light cold meal: The ability
to plan and prepare all aspects of a
light cold meal such as a bowl of
cereal and sandwich and cold drink.
11b. Makes a light hot meal: The ability to
plan and prepare all aspects of a light
hot meal such as heating a bowl of
soup and reheating a prepared meal.
11c. Light daily housework: The ability to
complete light daily housework to
maintain a safe home environment
such that the person is not at risk for
harm within their home. Examples
include wiping counter tops or doing
dishes.
11d. Heavier periodic housework: The
ability to complete heavier periodic
housework to maintain a safe home
environment such that person is not
risk for harm within their home.
Examples include doing laundry,
vacuuming, cleaning bathroom.
11e. Light shopping: Once at store, can
locate and select up to five needed
goods, take to check out, and
complete purchasing transaction.
11f. Telephone-answering call: The
ability to answer call in person’s
customary manner and maintain for 1
minute or longer. Does not include
getting to the phone.
11g. Telephone-placing call: The ability to
place call in person’s customary
manner and maintain for 1 minute or
longer. Does not include getting to
the phone.

6

Identifier (Assessor ID# / Recipient #) ___________

Section B

Functional Abilities and Goals

Instrumental Activities of Daily Living (continued)
Form Instructions:
Code the person’s usual performance during the past 3 days using the 6-point scale in Column A. If the person’s
performance changed during the past month, also code their most dependent performance in Column B. If the
person’s IADL performance was unchanged during the past month, column B should be coded the same as column
A. If the activity was not attempted, code the reason.
Please complete the IADL Priorities section at the bottom of this page.
CODING:
Safety and Quality of Performance – If
helper assistance is required because person’s
performance is unsafe or of poor quality score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent – Person completes the
activity by him/herself with no assistance
from a helper.
05. Setup or cleanup assistance – Helper
SETS UP or CLEANS UP; person
completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance –
Helper provides VERBAL CUES or
TOUCHING/STEADYING assistance as
person completes activity. Assistance
may be provided throughout the activity
or intermittently.
03. Partial/moderate assistance – Helper
does LESS THAN HALF the effort.
Helper lifts, holds or supports trunk or
limbs, but provides less than half the
effort.
02. Substantial/maximal assistance –
Helper does MORE THAN HALF the
effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent – Helper does ALL of the
effort. Person does none of the effort to
complete the activity. Or, the assistance
of 2 or more helpers is required for the
person to complete the activity.
If activity was not attempted, code reason:
07. Person refused.
09. Not applicable – Person does not usually
do this activity.
88. Not attempted due to short-term
medical condition or safety concerns.

Performance Level
Enter Codes in Boxes
B
A
Most
Usual

Dependent

11h. Medication management-oral
medications: The ability to prepare
and take all prescribed oral
medications reliably and safely,
including administration of the
correct dosage at the appropriate
times/ intervals.
11i. Medication managementinhalant/mist medications: The
ability to prepare and take all
prescribed inhalant/mist medications
reliably and safely, including
administration of the correct dosage
at the appropriate times/intervals.
11j. Medication management-injectable
medications: The ability to prepare
and take all prescribed injectable
medications reliably and safely,
including administration of the
correct dosage at the appropriate
times/intervals.
11k. Simple financial management: The
ability to complete financial
transactions such as counting coins,
verifying change for a single item
transaction or writing a check.
11l. Complex financial management:
The ability to complete financial
decision-making such as budgeting
and remembering to pay bills.

IADL Priorities: Please indicate your top two priorities in the area of instrumental activities of daily living for the
next six months.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________

7

Identifier (Assessor ID# / Recipient #) ___________

Section C

Assistive Devices

Assistive Devices for Everyday Activities
Form Instructions:
Identify the person’s need for and availability of each assistive device. If no assistive device is needed to complete selfcare, mobility, and instrumental activities of daily living, check “Not Applicable” box. If device is not used, code reason.
CODING:
Code the person’s usual need for, and
availability of, assistive devices to complete
self-care, mobility, or instrumental activities
of daily living.
02. Assistive device needed and available –
Person needs this device to complete
daily activities and has the device in the
home.
01. Assistive device needed but current
device unsuitable – Device is in home
but no longer meets person’s needs.
00. Assistive device needed but not
available – Person needs the device but
it is not available in the home.
If device is not used, code reason:
07. Person refused – Person chooses not to
use needed device.
09. Not applicable – Person does not need
this device.

Enter Codes in Boxes
12a.

Manual wheelchair

12b.

Motorized wheelchair or scooter

12c.

Specialized seating pad (e.g. airfilled, gel, shaped foam)

12d.

Mechanical lift

12e.

Walker

12f.

Walker with seat

12g.

Cane

12h.

Crutch(es)

12i.

Prosthetics

12j.

Orthotics/Brace

12k.

Bed rail

12l.

Electronic bed

12m.

Grab bars

12n.

Transfer board

12o.

Shower/commode chair

12p.

Walk/wheel-in shower

12q.

Glasses or contact lenses

12r.

Hearing aid

12s.

Communication device

12t.

Stair rails

12u.

Lift chair

12v.

Ramps

Other: _____________________
I have indicated all the devices needed
(check box)
Not Applicable – No assistive device needed
in past month (check box)

8

Identifier (Assessor ID# / Recipient #) ___________

Section D

Living Arrangements, Caregiver Assistance and Availability

Living Arrangements
13. Identify the person’s usual living arrangement during the past 3 days
and the past month.

A

Past 3 Days

B

Past month

CODING:
05. Person lives alone – no other residents in the home.
04. Person lives with others in the home – for example, family, friends,
or paid caregiver.
03. Person lives in congregate home – for example, assisted living, or
residential care home.
02. Person does not have a permanent home or is homeless.
01. Person was in a medical facility.

Availability of Assistance
14. Does the person have assistance in their home?
0. No – Do not code availability of assistance – skip to question 15a.
1. Yes – Continue to question 14a.
14a. Code the level of assistance in the person’s home (both paid and
unpaid) during the past month.

A

Paid

B

Unpaid

CODING:
05.
04.
03.
02.
01.

No assistance received
Occasional/short term assistance
Regular night time
Regular daytime
Around the clock

9

Identifier (Assessor ID# / Recipient #) ___________

Section D

Living Arrangements, Caregiver Assistance and Availability

Availability of Paid and Unpaid Assistance
Form Instructions:
Code the Paid caregiver’s usual ability and willingness to provide assistance with each activity during the past 3 days
in Column A and the Unpaid caregiver’s usual ability and willingness to provide assistance with each activity during
the past 3 days in Column B. If the activity was not attempted, code as not applicable (09).
Please complete the Living Arrangement and Caregiving Priorities section at the bottom of this page.
CODING:
Code safety and quality of BOTH paid and
unpaid caregiver assistance and their
willingness to provide assistance with each of
the following activities.
05. Assistance not needed – No assistance
needed.
04. Caregiver(s) currently provide
assistance – Person’s usual caregiver(s)
willing and able to provide needed
assistance.
03. Caregiver(s) need training/supportive
services to provide assistance –
Caregiver(s) available and need
assistance to provide support.
02. Unclear if caregiver(s) will provide
assistance– Caregiver(s) available in the
home but it is not clear if caregiver(s) will
provide needed assistance.
01. Assistance needed but no caregiver(s)
available – Person needs assistance but
no caregiver(s) available in the home.
00. Assistance needed but person declines
assistance – Person needs caregiving but
declines this assistance.
09. Not applicable – Person does not do this
activity.

Enter Codes in Boxes
B
A
Paid

Unpaid

15a.
15b.
15c.
15d.
15e.
15f.

15g.

Self-care assistance (for example,
bathing, dressing, toileting, or
eating/feeding).
Mobility assistance (for example,
bed mobility, transfers,
ambulating, or wheeling).
IADL assistance (for example,
making meals, housekeeping,
telephone, shopping, or finances).
Medication administration (for
example, oral, inhaled, or injectable
medications).
Medical procedures/treatments (for
example, changing wound dressing,
or home exercise program).
Management of equipment (for
example, oxygen, IV/infusion
equipment, enteral/parenteral
nutrition, or ventilator therapy
equipment and supplies).
Supervision (for example, due to
safety concerns).

15h.

Advocacy or facilitation of person’s
participation in appropriate medical
care (for example, transportation to
or from appointments).
16. Has the PAID caregiver(s) ability, willingness, or
availability changed during the past month?
0. No – it was the same (or better).
1. Yes – caregiver(s) had less ability, willingness,
or availability
17. Has the UNPAID caregiver(s) ability, willingness,
or availability changed during the past month?
0. No – it was the same (or better).
1. Yes – caregiver(s) had less ability, willingness
or availability.
Living Arrangement and Caregiving Priorities: Please indicate your top two priorities in the area of living
arrangements and caregiving for the next six months.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________

10