Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 201710-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 IRF-PAI instrument Final IRF-PAI Version 2.0 - Effective October 1 2018.pdf	Form and Instruction
CMS-10036 IRF-PAI Intrument Final IRF-PAI Version 1.5 - Effective October 1 2017.pdf	Form and Instruction
Appendix B IRF-PAI v1.3 to v1.4 Change Table.pdf Appendix B: Change table V1.3 to 1.4	IC Document
Appendix A IRF-PAI_V1.3 effective 10-1-15.pdf Appendix A: IRF-PAI V1.3	IC Document
Appendix B IRF-PAI Version 1.4 - Effective Octobe 1 2016.pdf Appendix B: IRF-PAI V1.4	IC Document
Appendix C - Proposed IRF-PAI Versions 1.5 and 2.0 Change Tables.pdf Appendix C: Change Tables V1.4 to 1.5 and V1.5 to 2.0	IC Document
IRF PRA Package Crosswalk.docx Crosswalk	IC Document

IC Title:

Inpatient Rehabilitation Facility - Patient Assessment Instrument

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	IRF-PAI instrument	Final IRF-PAI Version 2.0 - Effective October 1 2018.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10036	IRF-PAI Intrument	Final IRF-PAI Version 1.5 - Effective October 1 2017.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: 1,137

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	Previously Approved
Annual Number of Responses for this IC	402,311	43,311	359,000
Annual IC Time Burden (Hours)	227,151	30,071	197,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B: Change table V1.3 to 1.4	Appendix B IRF-PAI v1.3 to v1.4 Change Table.pdf	06/02/2017
Appendix A: IRF-PAI V1.3	Appendix A IRF-PAI_V1.3 effective 10-1-15.pdf	06/02/2017
Appendix B: IRF-PAI V1.4	Appendix B IRF-PAI Version 1.4 - Effective Octobe 1 2016.pdf	06/02/2017
Appendix C: Change Tables V1.4 to 1.5 and V1.5 to 2.0	Appendix C - Proposed IRF-PAI Versions 1.5 and 2.0 Change Tables.pdf	06/02/2017
Crosswalk	IRF PRA Package Crosswalk.docx	08/01/2017

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