Functional Assessment Standardized Items (FASI): Round 1

Testing Experience and Functional Tools: Functional Assessment Standardized Items (FASI) Based on the CARE Tool (CMS-10243)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1037 can be found here:

Documents and Forms

Document Name Document Type
FASIAssessorTrainingMarch508.pdf Instruction
CMS-10243 Consent Form FASIConsentAssentForms508 [rev 12-23-2016].pdf Form and Instruction
CMS-10243 Functional Assessment Standardized Items (FASI) TEFT072116FASIItems508 [rev 08-12-2016 by OSORA PRA].pdf Form and Instruction
ChangeCrosswalk072116Final508.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Functional Assessment Standardized Items (FASI): Round 1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FASIAssessorTrainingMarch508.pdf	No		Printable Only
Form and Instruction	CMS-10243	Functional Assessment Standardized Items (FASI)	TEFT072116FASIItems508 [rev 08-12-2016 by OSORA PRA].pdf	No		Fillable Printable
Form and Instruction	CMS-10243	Consent Form	FASIConsentAssentForms508 [rev 12-23-2016].pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,570	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,570	1,570
Annual IC Time Burden (Hours)	785	785
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	ChangeCrosswalk072116Final508.pdf	08/12/2016

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