Information Collection

Inpatient Rehabilitation Facility - Patient Assessment Instrument

IC 210555 under ICR 201810-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 CMS-10036.Proposed IRF-PAI Version 3.0 - Effective October 1 2019 (FY2020).pdf	Form and Instruction
Proposed IRF-PAI Version 3.0 Change Table.pdf IRF-PAI Change Table	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	CMS-10036.Proposed IRF-PAI Version 3.0 - Effective October 1 2019 (FY2020).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: 1,126

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	403,341	1,030	402,311
Annual IC Time Burden (Hours)	97,418	-129,733	227,151
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IRF-PAI Change Table	Proposed IRF-PAI Version 3.0 Change Table.pdf	05/24/2018

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