Information Collection

(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations

IC 7996 under ICR 201712-0938-004 · OMB 0938-0358.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0358 can be found here:

2021-06-01 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-437 (437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	Form and Instruction
CMS-437 Psychiatric Unit Criteria Worksheet CMS-437. Revised Instrument 05.03.18.docx	Form and Instruction
Exhibit A - Change Crosswalk for CMS-437. 08.31.17.docx Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 412.25-27

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-437	Psychiatric Unit Criteria Worksheet	CMS-437. Revised Instrument 05.03.18.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,616

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,616	2	1,614
Annual IC Time Burden (Hours)	1,212	808	404
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	Exhibit A - Change Crosswalk for CMS-437. 08.31.17.docx	12/05/2017

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